Introduction. In total hip arthroplasty, a high radiographic inclination angle (RI) of the acetabular component has been linked to short- and long-term complications. There are several factors that lead to RI outliers including cup version, pelvic orientation and angle of the cup introducer relative to the floor. The primary aim of this study was to analyse what increases the risk of having a cup with an RI outside the target zone when controlling cup orientation with a digital inclinometer. Methods. In this prospective study, we included 200 consecutive patients undergoing uncemented primary THA in the lateral decubitus position using a posterior approach. Preoperatively, the surgeon determined the target intraoperative inclination (IOI. target. ). The intra-operative inclination of the cup (IOI. cup. ) was measured with the aid of a digital inclinometer after seating of the acetabular component. Anteroposterior pelvic radiographs were made to measure the RI of the acetabular component. The target zones were defined as 30°-45° and 35°-45° of RI. The operative inclination relative to the sagittal plane of the pelvis (OI. math. ) was calculated based on the radiographic inclination and anteversion angle. The difference between two outcome measures was expressed as Δ. Results. The mean RI was 37.9° SD 4.7, there were 12 cases with RI outside the 30°– 45° zone (6%) and 53 outliers (26.5%) with RI outside the 35°-45° zone. The mean absolute ΔIOI. cup. -IOI. target. was 1.2° SD 1.0. The absolute ΔIOI. cup. -IOI. target. was less than 1° in 108 patients (54%), less than 2° in 160 patients (80%), less than 3° in 186 patients (93%), and in 14 patients (7%) the difference was 3°-5°. The mean pelvic motion (ΔOI. math. -IOI. cup. ) was 8.8° SD 3.9 (95% CI 8.2° to 9.3°). The absolute deviation from the mean ΔOI. math. -IOI. cup. , which corresponds with the amount of pelvic motion, was significantly higher in RI outliers compared with non-outliers for both the 30°-45° and 35°-45° inclination zone (7.4° SD 3.3 vs 2.8° SD 2.1 and 4.7° SD 2.8 vs 2.5° SD 2.0 respectively) (p<0.0001). A linear regression analysis demonstrated a strong correlation between ΔOI. math. -IOI. cup. and the RI of the cup (r. 2. =0.70; P<0.0001). A multiple regression was run to predict ΔOI. math. -IOI. cup. from gender, BMI, side and hip circumference. These variables statistically significantly predicted ΔOI. math. -OIa. cup. , F(4, 195) = 19,435, p<0.0001, R2 = 0.285, but only side (p=0.04) and hip circumference (p<0.0001) added statistically significantly to the prediction. Discussion and Conclusion. When using a digital inclinometer 94% of cups had a RI within a 30°-45° zone and 73.5% of cups within a 35°-45° zone using a predefined IOI. target. based on the patient's hip circumference. The difference between the IOI. target. and the IOI. cup. of the acetabular component was less than 3° in 93% and less than 5° in all patients signifying that the surgeons were able to implant the cup close to their chosen intra-operative orientation. Deviation from the mean ΔOI. math. -IOI. cup. was significantly bigger in the RI outliers indicating that RI outliers were caused by more or less than deviation of the sagittal plane of the pelvis at time of cup impaction

Introduction. Acetabular component orientation is an important determinant of outcome following total hip arthroplasty (THA). Although surgeons aim to achieve optimal cup orientation, many studies demonstrate their inability to consistently achieve this. Factors that contribute are pelvic orientation and the surgeon's ability to correctly orient the cup at implantation. The goal of this study was to determine the accuracy with which surgeons can achieve cup orientation angles. Methods. In this in vitro study using a calibrated left and right sawbone hemipelvis model, participants (n=10) were asked to place a cup mounted on its introducer giving different targets. Measurements of cup orientation were made using a stereophotogrammetry protocol to measure radiographic inclination and operative anteversion (OA). A digital inclinometer was used to measure the intra-operative inclination (IOI) which is the angle of the cup introducer relative to the floor. First, the participant stated his or her preferred IOI and OA and positioned the cup accordingly. Second, the participant had to position the cup parallel to the anteversion of the transverse acetabular ligament (TAL). Third, the participant had to position the cup at IOI angles of 35°, 40° and 45°. Fourth, the participant used the mechanical alignment guide (45° of IOI and 30° of OA) to orient the cup. Each task was analysed separately and subgroup analysis included left versus right side and hip surgeons versus non-hip surgeons. Results. For the first task, hip surgeons preferred smaller IOI and larger OA than non-hip surgeons, but there was no significant difference in accuracy between both groups. When aiming for TAL, both surgeon groups performed similar, but accuracy on the non-dominant side was significantly better compared with the dominant side (mean deviation 0.6° SD 2.4 versus −2.6° SD 2.3) (p=0.004). When aiming for a specific IOI target of 35°, 40° or 45°, non-hip surgeons outperformed hip surgeons (mean deviation form target IOI 1.9° SD 2.7 versus −3.1° SD 3.8) (p<0.0001) with less variance (p=0.03). Contrary to version, accuracy on the dominant side was significantly better compared with the non-dominant side (mean deviation −0.4° SD 3.4 versus −2.1° SD 4.8). When using a mechanical guide, surgeons performed similar (0.6° SD 1.2 versus −0.4° SD 2.1 for inclination p=0.11 and −0.5° SD 2.6 versus −1.8° SD 3.3 for version p=0.22) and these values did not differ significantly from the actual IOI and OA of the mechanical guide. When using a mechanical guide, there was no difference in accuracy between the dominant and non-dominant side. Conclusion. There was no difference in accuracy between hip surgeons and non-hip surgeons when they aimed for their preferred IOI and OA or used a mechanical guide. When aiming for a specific IOI target, non-hip surgeons outperformed hip surgeons. Hip surgeons overestimate IOI and underestimate OA, presumably because this helps to achieve the desired radiographic cup orientation. Regarding accuracy, the non-dominant side was better for version and the dominant side for inclination. When aiming for a specific IOI and OA target, using a mechanical guide is significantly better than freehand cup orientation

The angle of acetabular inclination is an important measurement in total hip replacement (THR) procedures. Determining the acetabular component orientation intra-operatively remains a challenge. An increasing number of innovators have described techniques and devices to achieve it. This paper describes a mechanical inclinometer design to measure intra-operative acetabular cup inclination. Then, the mechanical device is tested to determine its accuracy. The aim was to design an inclinometer to measure inclination without existing instrumentation modification. The device was designed to meet the following criteria: 1. measure inclination with acceptable accuracy (+/− 5o); 2. easy to use intra-operatively (handling & visualization); 3. adaptable and useable with majority of instrumentation kits without modification; 4. sterilizable by all methods; 5. robust/reusable. The prototype device was drafted by computer aided design (CAD) software. Then a prototype was constructed using a 3D printer to establish the final format. The final device was CNC machined from SAE 304 stainless steel. The design uses an eccentrically weighted flywheel mounted on two W16002-2RS ball bearings pressed into symmetrical housing components. The weighted wheel is engraved with calibrated markings relative to its mass centre. Device functioning is dependent on gravity maintaining the weighted wheel in a fixed orientation while the housing can adapt to the calibration allowing for determining the corresponding measurement. The prototype device accuracy was compared to a digital device. A digital protractor was used to create an angle. The mechanical inclinometer (user blinded to digital reading) was used to determine the angle and compared to the digital reading. The accuracy of the device compared to the standard freehand technique was assessed using a saw bone pelvis fixed in a lateral decubitus position. 18 surgeons (6 expert, 6 intermediate, 6 novice) were asked to place an uncemented acetabular cup in a saw bone pelvis to a target of 40 degrees. First freehand then using the inclinometer. The inclination was determined using a custom-built inertial measurement unit with the user blinded to the result. Comparison between the mechanical and digital devices showed that the mechanical device had an average error of −0.2, a standard deviation of 1.5, and range −3.3 to 2.6. The average root mean square error was 1.1 with a standard deviation of 0.9. Comparison of the inclinometer to the freehand technique showed that with the freehand component placement 50% of the surgeons were outside the acceptable range of 35–45 degrees. The use of the inclinometer resulted all participants to achieve placement within the acceptable range. It was noted that expert surgeons were more accurate at achieving the target inclination when compared to less experienced surgeons. This work demonstrates that the design and initial testing of a mechanical inclinometer is suitable for use in determining the acetabular cup inclination in THR. Experimental testing showed that the device is accurate to within acceptable limits and reliably improved the accuracy of uncemented cup implantation in all surgeons

Acetabular morphology and orientation differs from ethnic group to another. Thus, investigating the normal range of the parameters that are used to assess both was a matter of essence. Nevertheless, the main aim of this study was clarification the relationship between acetabular inclination (AI) and acetabular and femoral head arcs’ radii (AAR and FHAR). A cross-sectional retrospective study that had been done in a tertiary center where Computed tomography abdomen scouts’ radiographs of non-orthopedics patients were included. They had no history of pelvic or hips’ related symptoms or fractures in femur or pelvis. A total of 84 patients was included with 52% of them were females. The mean of age was 30.38± 5.48. Also, Means of AI were 38.02±3.89 and 40.15±4.40 (P 0.02, significant gender difference) for males and females, respectively. Nonetheless, Head neck shaft angle (HNSA) means were 129.90±5.55 and 130.72±6.62 for males and females, respectively. However, AAR and FHAR means for males and females were 21.3±3.1mm, 19.9±3.1mm, P 0.04 and 19.7±3.1mm, 18.1±2.7mm, P 0.019, respectively. In addition, negative significant correlations were detected between AI against AAR, FHAR, HNSA and body mass index (BMI) (r 0.529, P ≤0.0001, r 0.445, P ≤0.0001, r 0.238, P 0.029, r 0.329, P ≤0.007, respectively). On the other hand, high BMI was associated with AAR and FHAR (r 0.577, P 0.0001 and r 0.266, p 0.031, respectively). This study shows that high AI is correlated with lower AAR, FHAR. Each ethnic group has its own normal values that must be studied to tailor the path for future implications in clinical setting

Background. Positioning of the acetabular component in total hip arthroplasty has profound effects on the biomechanics, stability and wear of the prosthesis. Normal anatomical position in females is 57 degrees (50 – 67 degrees) inclination with 19 degrees (9 – 32 degrees) of anteversion, whilst in males 56 degrees of inclination (48 – 66 degrees) with 19 degrees (9 – 32 degrees) is normal. In total hip arthroplasty, inclination recommendation ranges from 30 – 50 degrees. The aim of this study was to radiographically measure acetabular component position in total hip arthroplasty and compare to normal values. Method. The Widmer method was used by two independent observers to radiographically measure inclination in 522 patients using standard AP radiographs. Primary measures and variables were statistically analysed as was inter and intra observer reliability. All patients included within the study received total hip arthroplasty for age related degenerative changes to the hip. Operations were undertaken by 17 separate consultants or senior registrars under their care. Results. Overall mean inclination was measured at 45.27 degrees with a range of 26 – 68 degrees. Statistically significant differences were observed between cemented 45.9o and non-cemented hips 43.9 degrees (p= 0.018), Simple 45.5 degrees vs complex 42.1 degrees (p=0.003) and Male 44.3 degrees vs Female 46.2 degrees (p=0.0198). No statistical difference was seen between consultant and registrar (p=0.211) and right vs left (p=0.768). Inter observer reliability was seen to be 0.91 whilst intra observer reliability 0.96. Conclusion. Although a large range of outcomes were observed, 95% of radiographs reviewed fell within a range of 33.6 – 56.9 degrees Variables such as surgical positioning, patient anatomy/body habitus, surgical technique, instrumentation likely influenced abnormal results. Abnormal positioning may have effects such as eccentric wear and dislocation, however, and such findings are yet to be observed in the study group

Introduction. Glenoid inclination, defined as the angle formed by the intersection of a line made of the most superior and inferior points of the glenoid and a line formed by the supraspinatus fossa, has been postulated to impact the mechanical advantage of the rotator cuff in shoulder abduction. An increase in glenoid inclination has previously been reported in patients with massive rotator cuff tears and multiple studies have correlated rotator cuff tears to an increase of the critical shoulder angle, an angle comprised of both the glenoid inclination and acromical index. Glenoid inclination is best measured by the B-angle as it has been shown to be both an accurate and reliable. The purpose of this study was to determine the correlation of glenoid inclination and the presence of degenerative rotator cuff tears. Methods. Data was prospectively collected for study patients assigned to one of two groups. The tear group consisted of patients with degenerative, atraumatic rotator cuff tears, confirmed by MRI and the control group consisted of healthy volunteers without shoulder pain. Inclusion criteria for both groups included age 45 or older. Exclusion criteria included history of previous shoulder surgery, previous patient-recalled injury to the shoulder, presence of glenoid weak, and previous humerus or glenoid fracture. Patients were also excluded from the control group if any shoulder pain or history of rotator cuff disease was present. All patients had standard anterior/posterior shoulder radiographs taken and glenoid inclination was digitally measured with Viztek OpalRad PACS software (Konica Minolta, Tokyo, Japan). The beta angle was measured to determine the glenoid inclincation. Statistical analysis was performed using SPSS version 23 (IBM, Aramonk, NY). Patient age and glenoid inclination were examined with the Shapiro-Wilk test of normality and then compared with student t tests. Gender distribution was compared with chi square test. A p-value of 0.05 was used to represent significance. Results. The study included 26 patients in the tear group and 23 patients in the control group. There was no difference in the age of the two groups (57 vs 54, p=0.292) or gender distribution (p=0.774). The average glenoid inclination was 11.18 (SD=2.67) degrees for the tear group and 5.97 (SD=2.55) degrees for the control group. This difference was statistically significant (p<0.001). Discussion. Glenoid inclination is significantly increased in patients with degenerative rotator cuff tears compared to healthy controls. Tendon overload secondary to increased glenoid inclination may be the primary anatomical factor contributing to the development of degenerative rotator cuff tears

Metal-on-metal (MOM) hip arthroplasty, including resurfacing, has become the subject of recent research and debate. There is the perceived benefit of improved wear rates of bearing surfaces leading to superior durability and performance of these types of implant. An associated feature of MOM bearing surfaces is the generation of metal ions. These can have local and systemic cytotoxic effects. An immunoloigical response has been suggested, however, metal wear debris may cause direct damage to cellular DNA. Studies have shown that release of these ions is related to bearing diameter and component alignment. However, little is known about the relationship between metal ion levels and implant survivorship. The MHRA has published guidelines on the follow-up of patients with MOM implants including measurement of serum ion levels and cross sectional imaging. Between February 2001 and November 2009, 135 patients (164 hips) had MOM resurfacing arthroplasty at our institution. We report a retrospective analysis of the data generated by review of these patients. Of the 135 patients, 91 were identified for clinical review. Each patient had serum metal ion levels measured, plain AP radiographs of the pelvis examined and, in the presence of raised metal ions, a Metal Artefact Reduction Sequence (MARS) MRI performed. 27 patients (35 hips) had raised metal ion levels (Cobalt and Chromium). Patients with raised metal ion levels had a mean acetabular cup inclination of 52.7 degrees compared with a mean inclination of 48.6 degrees in patients with normal ion levels (p<0.05). MARS MRI in the raised ion group revealed 9 patients with appearances suggestive of ALVAL. A number of these patients had hip revision surgery with the remainder awaiting potential revision. These findings reflect current evidence suggesting a relationship between sub-optimal component position and raised metal ion levels and an increased rate of ALVAL

Reorientating pelvic osteotomies are performed to improve femoral head coverage and secondary degenerative arthritis. A rectangular triple pelvic innominate osteotomy (3PIO) is performed in symptomatic cases. However, deciding optimal screw fixation type to avoid complications is questionable. Therefore, this study aimed to investigate the biomechanical behavior of two different acetabular screw configurations used for rectangular 3PIO osteosynthesis. It was hypothesized that bi-directional screw fixation would be biomechanically superior to mono-axial screw fixation technique. A rectangular 3PIO was performed in twelve right-side artificial Hemi-pelvises. Group 1 (G1) had two axial and one transversal screw in a bi-directional orientation. Group 2 (G2) had three screws in the axial direction through the iliac crest. Acetabular fragment was reoriented to 10.5° inclination in coronal plane, and 10.0° increased anteversion along axial plane. Specimens were biomechanically tested until failure under progressively increasing cyclic loading at 2Hz, starting at 50N peak compression, increasing 0.05N/cycle. Stiffness was calculated from machine data. Acetabular anteversion, inclination and medialization were evaluated from motion tracking data from 250-2500 at 250 cycle increments. Failure cycles and load were evaluated for 5° change in anteversion. Stiffness was higher in G1 (56.46±19.45N/mm) versus G2 (39.02±10.93N/mm) but not significantly, p=0.31. Acetabular fragment anteversion, inclination and medialization increased significantly each group (p≤0.02) and remained non-significantly different between the groups (p≥0.69). Cycles to failure and failure load were not significantly different between G1 (4406±882, 270.30±44.10N) and G2 (5059±682, 302.95±34.10N), p=0.78. From a biomechanical perspective, the present study demonstrates that a bi-directional screw orientation does not necessarily advantageous versus mono-axial alignment when the latter has all three screws evenly distributed over the osteotomy geometry. Moreover, the 3PIO fixation is susceptible to changes in anteversion, inclination and medialization of the acetabular fragment until the bone is healed. Therefore, cautious rehabilitation with partial weight-bearing is recommended

Dual mobility hip arthroplasty utilizes a freely rotating polyethylene liner to protect against dislocation. As liner motion has not been confirmed in vivo, we investigated the liner kinematics in vivo using dynamic radiostereometry. 16 patients with Anatomical Dual Mobility acetabular components were included. Markers were implanted in the liners using a drill guide. Static RSA recordings and patient reported outcome measures were obtained at post-op and 1-year follow-up. Dynamic RSA recordings were obtained at 1-year follow-up during a passive hip movement: abduction/external rotation, adduction/internal rotation (modified FABER-FADIR), to end-range and at 45° hip flexion. Liner- and neck movements were described as anteversion, inclination and rotation. Liner movement during modified FABER-FADIR was detected in 12 of 16 patients. Median (range) absolute liner movements were: anteversion 10° (5–20), inclination 6° (2–12), and rotation 11° (5–48) relative to the cup. Median absolute changes in the resulting liner/neck angle (small articulation) was 28° (12–46) and liner/cup angle (larger articulation) was 6° (4–21). Static RSA showed changes in median (range) liner anteversion from 7° (-12–23) postoperatively to 10° (-3–16) at 1-year follow-up and inclination from 42 (35–66) postoperatively to 59 (46–80) at 1-year follow-up. Liner/neck contact was associated with high initial liner anteversion (p=0.01). The polyethylene liner moves over time. One year after surgery the liner can move with or without liner/neck contact. The majority of movement is in the smaller articulation between head and liner

Odontoid fracture of the second cervical vertebra (C2) is the most common spinal fracture type in elderly patients. However, very little is known about the biomechanical fracture mechanisms, but could play a role in fracture prevention and treatment. This study aimed to investigate the biomechanical competence and fracture characteristics of the odontoid process. A total of 42 human C2 specimens (14 female and 28 male, 71.5 ± 6.5 years) were scanned via quantitative computed tomography, divided in 6 groups (n = 7) and subjected to combined quasi-static loading at a rate of 0.1 mm/s until fracturing at inclinations of −15°, 0° and 15° in sagittal plane, and −50° and 0° in transverse plane. Bone mineral density (BMD), specimen height, fusion state of the ossification centers, stiffness, yield load, ultimate load, and fracture type according to Anderson and d'Alonzo were assessed. While the lowest values for stiffness, yield, and ultimate load were observed at load inclination of 15° in sagittal plane, no statistically significant differences could be observed among the six groups (p = 0.235, p = 0.646, and p = 0.505, respectively). Evaluating specimens with only clearly distinguishable fusion of the ossification centers (n = 26) reveled even less differences among the groups for all mechanical parameters. BMD was positively correlated with yield load (R² = 0.350, p < 0.001), and ultimate load (R² = 0.955, p < 0.001), but not with stiffness (p = 0.070). Type III was the most common fracture type (23.5%). These biomechanical outcomes indicate that load direction plays a subordinate role in traumatic fractures of the odontoid process in contrast to BMD which is a strong determinant of stiffness and strength. Thus, odontoid fractures appear to result from an interaction between load magnitude and bone quality

Pre-operative 3D glenoid planning improves component placement in terms of version, inclination, offset and orientation. Version and inclination measurements require the position of the inferior angle. As a consequence, current planning tools require a 3D model of the full scapula to accurately determine the glenoid parameters. Statistical shape models (SSMs) can be used to reconstruct the missing anatomy of bones. Therefore, the objective of this study is to develop and validate an SSM for the reconstruction of the inferior scapula, hereby reducing the irradiation exposure for patients. The training dataset for the statistical shape consisted of 110 CT images from patients without observable scapulae pathologies as judged by an experienced shoulder surgeon. 3D scapulae models were constructed from the segmented images. An open-source non-rigid B-spline-based registration algorithm was used to obtain point-to-point correspondences between the models. A statistical shape model was then constructed from the dataset using principal component analysis. Leave-one-out cross-validation was performed to evaluate the accuracy of the predicted glenoid parameters from virtual partial scans. Five types of virtual partial scans were created on each of the training set models, where an increasing amount of scapular body was removed to mimic a partial CT scan. The statistical shape model was reconstructed using the leave-one-out method, so the corresponding training set model is no longer incorporated in the shape model. Reconstruction was performed using a Monte Carlo Markov chain algorithm, random walk proposals included both shape and pose parameters, the closest fitting proposal was selected for the virtual reconstruction. Automatic 3D measurements were performed on both the training and reconstructed 3D models, including glenoid version, inclination, glenoid centre point position and glenoid offset. In terms of inclination and version we found a mean absolute difference between the complete model and the different virtual partial scan models of 0.5° (SD 0.4°). The maximum difference between models was 3° for inclination and 2° for version. For offset and centre point position the mean absolute difference was 0 mm with an absolute maximum of 1 mm. The magnitude of the mean and maximum differences for all anatomic measurements between the partial scan and complete models is smaller than the current surgical accuracy. Considering these findings, we believe a SSM based reconstruction technique can be used to accurately reconstruct the glenoid parameters from partial CT scans

Abstract. Objectives. Accurate orientation of the acetabular component during a total hip replacement is critical for optimising patient function, increasing the longevity of components, and reducing the risk of complications. This study aimed to determine the validity of a novel VR platform (AescularVR) in assessing acetabular component orientation in a simulated model used in surgical training. Methods. The AescularVR platform was developed using the HTC Vive® VR system hardware, including wireless trackers attached to the surgical instruments and pelvic sawbone. Following calibration, data on the relative position of both trackers are used to determine the acetabular cup orientation (version and inclination). The acetabular cup was manually implanted across a range of orientations representative of those expected intra-operatively. Simultaneous readings from the Vicon® optical motion capture system were used as the ‘gold standard’ for comparison. Correlation and agreement between these two methods was determined using Bland-Altman plots, Pearson's correlation co-efficient, and linear regression modelling. Results. A total of 55 separate orientation readings were obtained. The mean average difference in acetabular cup version and inclination between the Vicon and VR systems was 3.4° (95% CI: −3–9.9°), and −0.005° (95% CI: −4.5–4.5°) respectively. Strong positive correlations were demonstrated between the Vicon and VR systems in both acetabular cup version (Pearson's R = 0.92, 99% CI: 0.84–0.96, p<0.001), and inclination (Pearson's R = 0.94, 99% CI: 0.88–0.97, p<0.001). Using linear regression modelling, the adjusted R. 2. for acetabular version was 0.84, and 0.88 for acetabular inclination. Conclusion. The results of this study indicate that the AescularVR platform is highly accurate and reliable in determining acetabular component orientation in a simulated environment. The AescularVR platform is an adaptable tracking system, which may be modified for use in a range of simulated surgical training and educational purposes, particularly in orthopaedic surgery. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

3D accurate measurements of the skeletal structures of the foot, in physiological and impaired subjects, are now possible using Cone-Beam CT (CBCT) under real-world loading conditions. In detail, this feature allows a more realistic representation of the relative bone-bone interactions of the foot as they occur under patient-specific body weight conditions. In this context, varus/valgus of the hindfoot under altered conditions or the thinning of plantar tissues that occurs with advancing age are among the most complex and interesting to represent, and numerous measurement proposals have been proposed. This study aims to analyze and compare these measurements from CBCT in weight-bearing scans in a clinical population. Sixteen feet of diabetic patients and ten feet with severe adult flatfoot acquired before/after corrective surgery underwent CBCT scans (Carestream, USA) while standing on the leg of interest. Corresponding 3D shapes of each bone of the shank and hindfoot were reconstructed (Materialise, Belgium). Six different techniques found in the literature were used to calculate the varus/valgus deformity, i.e., the inclination of the hindfoot in the frontal plane of the shank, and the distance between the ground and the metatarsal heads was calculated along with different solutions for the identification of possible calcifications. Starting with an accurate 3D reconstruction of the skeletal structures of the foot, a wide range of measurements representing the same angle of hindfoot alignment were found, some of them very different from each other. Interesting correlations were found between metatarsal height and subject age, significant in diabetic feet for the fourth and fifth metatarsal bones. Finally, CBCT allows 3D assessment of foot deformities under loaded conditions. The observed traditional measurement differences and new measurement solutions suggest that clinicians should consider carefully the anatomical and functional concepts underlying measurement techniques when drawing clinical and surgical conclusions

Variations in component positioning of total hip replacements can lead to edge loading of the liner, and potentially affect device longevity. These effects are evaluated using ISO 14242:4 edge loading test results in a dynamic system. Mediolateral translation of one of the components during testing is caused by a compressed spring, and therefore the kinematics will depend on the spring stiffness and damping coefficient, and the mass of the translating component and fixture. This study aims to describe the sensitivity of the liner plastic strain to these variables, to better understand how tests using different simulator designs might produce different amounts of liner rim deformation. A dynamic explicit deformable finite element model with 36mm Pinnacle metal-on-polyethylene bearing geometry (DePuy Synthes, Leeds, UK) was used with material properties for conventional UHMWPE. Setup was 65° clinical inclination, 4mm mismatch, 70N swing phase load, and 100N/mm spring. Fixture mass was varied from 0.5-5kg, spring damping coefficient was varied from 0-2Ns/mm. They were changed independently, and in combination. Maximum separation values were relatively insensitive to changes in the mass, damping coefficient, or both. The sensitivity of peak plastic strain, to this range of inputs, was similar to changing the swing phase load from 70N to approximately 150N – 200N. Increasing the fixture mass and/or damping coefficient increased the peak plastic strain, with values from 0.15-0.19. Liner plastic deformation was sensitive to the spring damping and fixture mass, which may explain some of the differences in fatigue and deformation results in UHMWPE liners tested on different machines or with modified fixtures. These values should be described when reporting the results of ISO14242:4 testing. Acknowledgements. Funded by EPSRC grant EP/N02480X/1; CAD supplied by DePuy Synthes

Objectives. Acetabular component orientation in total hip arthroplasty (THA) influences results. Intra-operatively, the natural arthritic acetabulum is often used as a reference to position the acetabular component. Detailed information regarding its orientation is therefore essential. The aim of this study was to identify the acetabular inclination and anteversion in arthritic hips. Methods. Acetabular inclination and anteversion in 65 symptomatic arthritic hips requiring THA were measured using a computer navigation system. All patients were Caucasian with primary osteoarthritis (29 men, 36 women). The mean age was 68 years (SD 8). Mean inclination was 50.5° (SD 7.8) in men and 52.1° (SD 6.7) in women. Mean anteversion was 8.3° (SD 8.7) in men and 14.4° (SD 11.6) in women. . Results. The difference between men and women in terms of anteversion was significant (p = 0.022). In 75% of hips, the natural orientation was outside the safe zone described by Lewinnek et al (anteversion 15° ± 10°; inclination 40° ± 10°). Conclusion. When using the natural acetabular orientation to guide component placement, it is important to be aware of the differences between men and women, and that in up to 75% of hips natural orientation may be out of what many consider to be a safe zone. Cite this article: Bone Joint Res 2015;4:6–10

Background. Trust in the validity of a measurement tool is critical to its function in both clinical and educational settings. Acetabular cup malposition within total hip arthroplasty (THA) can lead to increased dislocation rates, impingement and increased wear as a result of edge loading. We have developed a THA simulator incorporating a foam/Sawbone pelvis model with a modified Microsoft HoloLens® augmented reality (AR) headset. We aimed to measure the trueness, precision, reliability and reproducibility of this platform for translating spatial measurements of acetabular cup orientation to angular values before developing it as a training tool. Methods. A MicronTracker® stereoscopic camera was integrated onto a HoloLens® AR system. Trueness and precision values were obtained through comparison of the AR system measurements to a gold-standard motion capture system”s (OptiTrack®) measurements for acetabular cup orientation on a benchtop trainer, in six clinically relevant pairs of anteversion and inclination angles. Four surgeons performed these six orientations, and repeated each orientation twice. Pearson”s coefficients and Bland-Altman plots were computed to assess correlation and agreement between the AR and Motion Capture systems. Intraclass correlation coefficients (ICC) were calculated to evaluate the degree of repeatability and reproducibility of the AR system by comparing repeated tasks and between surgeons, respectively. Results. The trueness of the AR system was 0.24° (95% CI limit 0.92°) for inclination and 0.90° (95% CI limit 1.8°) for anteversion. Precision was 0.46° for inclination and 0.91° for anteversion. There was significant correlation between the two methods for both inclination (r = 0.996, p<0.001) and anteversion (r = 0.974, p<0.001). Repeatability for the AR system was 0.995 for inclination and 0.989 for anteversion. Reproducibility for the AR system was 0.999 for inclination and 0.995 for anteversion. Conclusion. Measurements obtained from the enhanced HoloLens® AR system were accurate and precise in regards to determining angular measurements of acetabular cup orientation. They exceeded those of currently used methods of cup angle determination such as CT and computer-assisted navigation. Measurements obtained were also highly repeatable and reproducible, therefore this platform is accurately validated for use in a THA training simulator

Background. Many factors contribute to the occurrence of edge-loading conditions in hip replacement; soft tissue tension, surgical position, patient biomechanical variations and type of activities, hip design, etc. The aim of this study was to determine the effect of different levels of rotational and translational surgical positioning of hip replacement bearings on the occurrence and severity of edge-loading and the resultant wear rates. Method. The Leeds II Hip-Joint Simulator and 36mm diameter alumina matrix composite ceramic bearings (BIOLOX delta, DePuy Synthes, UK) were used in this study. Different levels of mismatch between the reconstructed rotational centres of the head and the cup were considered (2, 3 and 4mm) in the medial-lateral axis. Two cup inclination angles were investigated; an equivalent to 45 and 65 degrees in-vivo, thus six conditions (n=6 for each condition) were studied in total with three million cycles completed for each condition. The wear of the ceramic-on-ceramic bearings were determined using a microbalance (Mettler Toledo, XP205, UK) and the dynamic microseparation displacement was measured using a Liner Variable Differential Transformer. Results. When a translational joint centre mismatch was coupled with a higher cup inclination angle, the severity of edge-loading increased when compared with the effect of those variables applied individually. Increasing the medial-lateral joint centre mismatch from 2 to 3 to 4mm resulted in increased wear rates under both cup inclination angles, with the 65 degree cup inclination angle having significantly higher wear rate than the cup inclination angle of 45 degree (p=0.02, p=0.02, and p<0.01 respectively). Conclusion. The cups with a 45 degree inclination angle showed greater resistance to dynamic microseparation as a result of joint centre mismatch. This study demonstrated that optimal position should not only consider the rotational position of the acetabular cup but also the relative centres of rotation of the head and the cup. Disclosure. John Fisher is a paid consultant to DePuy Synthes. Jonathan Thompson and Graham H. Issac are employees at DePuy Synthes

Introduction and Objective. The aim of this study was to evaluate whether CT-based pre-operative planning, integrated with intra-operative navigation could improve glenoid baseplate fixation and positioning by increasing screw length, reducing number of screws required to obtain fixation and increasing the use of augmented baseplate to gain the desired positioning. Reverse total shoulder arthroplasty (RSA) successfully restores shoulder function in different conditions. Glenoid baseplate fixation and positioning seem to be the most important factors influencing RSA survival. When scapular anatomy is distorted (primitive or secondary), optimal baseplate positioning and secure screw purchase can be challenging. Materials and Methods. Twenty patients who underwent navigated RSA (oct 2018 and feb 2019) were compared retrospectively with twenty patients operated on with a conventional technique. All the procedures were performed by the same surgeon, using the same implant in cases of eccentric osteoarthritis or complete cuff tear. Exclusion criteria were: other diagnosis as proximal humeral fractures, post-traumatic OA previously treated operatively with hardware retention, revision shoulder arthroplasty. Results. The NAV procedure required mean 11 (range 7–16) minutes more to performed than the conventional procedure. Mean screw length was significantly longer in the navigation group (35.5+4.4 mm vs 29.9+3.6 mm; p . .001). Significant higher rate of optimal fixation using 2 screws only (17 vs 3 cases, p . .019) and higher rate of augmented baseplate usage (13 vs 4 cases, p . .009) was also present in the navigation group. Signficant difference there is all in function outcomes, DASH score is 15.7 vs 29.4 and constant scale 78.1 vs 69.8. Conclusions. The glenoid component positioning in RSA is crucial to prevent failure, loosening and biomechanical mismatch, coverage by the baseplate of the glenoid surface, version, inclination and offset are all essential for implant survival. This study showed how useful 3D CT-based planning helps in identifying the best position of the metaglena and the usefulness of receiving directly in the operation theater real-time feedback on the change in position. This study shows promising results, suggesting that improved baseplate and screw positioning and fixation is possible when computer-assisted implantation is used in RSA comparing to a conventional procedure

Introduction and Objective. The patients with a total hip arthroplasty is growing in world manly in Europe and USA, and this solution present a high success at 10years in several orthopaedic registers. The application of total press-fit hip fixation presents the most used solution, but presents some failures associated to the acetabular component fixation, associated to the load transfer and bone loss at long term. The aim of this work is to investigate the influence of different acetabular bone loss in the strain distribution in iliac bone. To evaluate implant fixation, an experimental study was performed using acetabular press-fit component simulating different acetabular bone loss and measuring the strain distribution. Materials and Methods. The experimental samples developed was based in an iliac bone model of Sawbones supplier and a acetabular component Titanium (Stryker) in a condition press-fit fixation and was implanted according surgical procedure with 45º inclination angle and 20º in the anteversion angle. Were developed five models with same initial bone, one with intact condition simulating the cartilage between bones and four with different bone loss around the acetabular component. These four models representing the evolution of bone support of acetabular components presented in the literature. The evolution of bone loss was imposed with a CAD CAM process in same iliac bone model. The models were instrumented with 5 rosettes in critical region at the cortical bone to measure the strain evolution along the process. Results. The results of strain gauges present the influence of acetabular component implantation, reducing the bone strains and presented the effect of the strain shielding. The acetabular component works as a shield in the load transfer. The critical region is the posterior region with highest principal strains and the strain effect was observed with different bone loss around acetabular component. The maximum value of principal strain was observed in the intact condition in the anterior region, with 950μ∊. In the posterior superior region, the effect of bone loss is more important presenting a reduction of 500% in the strains. The effect of bone loss is presented in the strains induced with acetabular implantation, in the first step of implantation the maximum strain was 950μ∊ and in the last model the value was 50μ∊, indicating lower press-fit fixation. Conclusions. The models developed allows study the effect of bone loss and acetabular implant fixation in the load transfer at the hip articulation. The results presented a critical region as the anterior-superior and the effect of strain shielding was observed in comparison with intact articulation. The results of press-fit fixation present a reduction of implant stability along bone loss. The process of bone fixation developed present some limitation associated to the bone adhesion in the interface, not considered. Acknowledgement. This work was supported by POCI-01-0145-FEDER-032486,– FCT, by the FEDER, with COMPETE2020 - (POCI), FCT/M

Positioning of the hip resurfacing is crucial for its long term survival and is critical in young patients for some reasons; manly increase the wear in the components and change the load distribution. THR have increased in the last years, mainly in young patients between 45 to 59 years old. The resurfacing solution is indicated for young patients with good bone quality. A long term solution is required for these patients to prevent hip revision. The resurfacing prosthesis Birmingham Hip Resurfacing (BHR) was analyzed in the present study by in vitro experimental studies. This gives indications for surgeons when placing the acetabular cup. One synthetic left model of composite femur (Sawbones®, model 3403), which replicates the cadaveric femur, and four composite pelvic bones (Sawbones®, model 3405), were used to fix the commercial models of Hip resurfacing (Birmingham model). The resurfacing size was chosen according to the head size of femurs with 48 mm head diameter and a cup with 58 mm. They were introduced by an experimented surgeon with instrumental of prosthesis. The cup is a press fit system and the hip component was cemented using bone cement Simplex, Stryker Corp. The acetabular cup was analyzed in 4 orientations; in anteverion with 15º and 20°; and in inclination 40 and 45°. Combinations of these were also considered. The experimental set-up was applied according to a system previously established by Ramos et al. (2013) in the anatomic position. The femur rotates distally and the Pelvic moves vertically as model changes, such that the same boundary conditions are satisfied. This system allows compensating motions of the acetabular cup orientation. A vertical load of 1700 N was applied on all cases, which have resulted in joint reaction force of 2.4 kN. The femur and iliac bone was instrumented with rosettes. 5 repetitions at each position were conducted. When the femur was instrumented with three rosettes in medial, anterior and posterior aspect, the maximum strain magnitude was observed in the medial aspect of femur with a minimum principal strain of −2070µε for 45° inclination and 20° of anterversion. The pubic region was found most critical region after instrumenting the Iliac bone with four rosettes, with a minimum principal strain around −2500µε (rosette 1), for the 45° inclination and 20° of anterversion. We have observed the great influence of the inclination on the strain distribution, changing its magnitude from compression to traction in different bone regions. The minimum principal strain is more critical in medial aspect of the femur and the influence of strain is about 7% when orientation and inclination change. The maximum influence was observed in the anterior aspect, where the anteversion presents a significant influence. The results show the interaction between inclination and anterversion in all aspects, being observed lower values in lower angles. The orientation of the acetabular cup significantly influences the strain distribution on the iliac surface. Besides, as anterversion increases, more strains are induced, mainly in the region of iliac body (rosette 3)