The volume of intraoperative blood loss is measured and reported by OR nurses in many hospitals and doctors do not usually measure it by themselves. To measure intraoperative blood loss accurately is such a difficult task that many measurement errors occur due to various factors. However, it is important to obtain a more correct measurement for performing a safe operation and stable anesthesia control. In total hip arthroplasty (THA) we had experienced massive intraoperative blood loss errors and later identified the two major causes of these errors. One is the excess volume of infusions for irrigation infusions, and the other is the validity and reliability of the scales on infusion containers. To accurately measure intraoperative blood loss, we should know these two important factors of intraoperative blood loss errors. In arthroplasty we use many infusions for irrigation of the operative field. The labeled (nominal) volume of infusion containers do not accurately indicate the volume of infusions in the container. This is even defined by the WHO international pharmacopoeia (pharmaceutical laws), US, EU, and Japanese pharmacopoeia. According to these pharmacopoeia, the actual volume of infusions is (must be) not less than the labeled (nominal) volume. Moreover, the upper limit of excess volume is not regulated so far. This results in all parenteral infusions (i.e., I.V infusion bags, or bottles of saline) having excess volume compared to their respective labeled volumes. We also have verified the accuracy of volume scales on the infusions bags and bottles and found out some products have inaccuracies that we cannot ignore. After inquiring the pharmaceutical companies about the information concerning excess volume of infusions, we discovered that the excess volume is 2–5% higher than the labeled (nominal) volume depending on the product and company. (e.g., One product has around 3140ml in the container labeled 3000ml)Introduction
Case report
Since 1989 we have been using custom lateral-flare stems. Using this stem, its lateral flare can produce high proximal fit and less fit in distal part. Applying this automatic designing software to the average femoral geometries, we can make off the shelf high proximal fit stem (Revelation ®). Putting the off the shelf stem, the original center of the femoral heads were well reproduced. But in DDH cases, severe deformities around hip sometimes make complicated difficulty for better functional reconstruction. They are high hip center such as Crowe II-IV, shortening of the femoral neck, high anteversion etc. DDH cases are well known to have higher anteversion than non DDH cases. There would be no definite explanations for it. The high anteversion would not always be harmful for the preoperative patients. But in some cases, osteophytes are observed at posterior side of the femoral head which make another sphere with different centre. We can guess that the patient's biomechanics had not been matched with the original anteversion. Then posterior osteophytes can correct inappropriate anteversion (self-reduction.) (Fig.1) In those patients, reduction of the anteversion by putting stems twisted into the canal or using modular stems are sometimes done by the surgeons' decision. Younger DDH cases can also be treated with THA, because of the complicated deformities or biomechanical disorders. Short stems are expected to reduce operative invasion and stress shielding then can reserve bone quality and quantity. From these point of view to improve the understanding of the characteristics of the DDH anteversion, and design a DDH oriented short stem could be one of good solution for those cases.
For the better understanding of the high anteversion 57 femora (mean anteversion: 34.4 deg.) were analyzed slice by slice. The direction of femoral head centre, lesser trochanter (LTR), linea aspera (aspera) just below LTR, aspera in the middle of the femur and aspera between the last 2 sections. All of the directions were assessed from PC line To clarify the meaning of the head osteophytes, 35 operated cases were analyzed the extent of the head osteophytes. According to the results, a DDH oriented short stem was designed.Introduction
Method
In DDH cases often have high anteversion. They also often have high hip center. THA for those cases sometimes requires subtrochanteric derotational/shortening osteotomy. To achieve good results of the surgery, accurate preoperative planning based on biomechanics of the high anteversion cases, method for accurate application of the plan, and stable fixation are very important. At ISTA 2008, we have reported that the location of the anteversion exist several centimeters below the lesser trochanter. Independently from the extent of anteversion, femoral head, grater trochanter, and lesser trochanter are aligned in the same proportion. We have also reported in 2007, in improper high anteversion cases, many cases grow osteophytes posterior side of femoral head to reduce it functionally. In 2014, we reported about development of the stem for subtrochanteric osteotomy. (ModulusR)[Fig.1] In the present study, we established systematic planning way for estimate proper derotation and shortening and apply it for the surgery. Leg alignment during walking were well observed. According to the CT, 3D geometry of the femur, anteversion in hip joint and its compensation by the osteophyte, and knee rotation were measured. It was divided into proximal part and distal part at several centimeter below the lesser trochanter. Adequate hip local anteversion was determined by local original anteversion – compensation if IR-ER can be done. Keeping that anteversion for the proximal part, distal part was rotated as knee towards front. Thus derotation angle was decided. Using 3D CAD (Magics®) proper size of Modulus R was selected and overlapping with canal was extracted then its center of gravity was calculated. This level is decided as the height of osteotomy to obtain equal fixation to both proximal and distal part.[Fig.2] If the derotation angle is less than 15 degree, modular neck adjustment was selected first. By trial reduction and motion test, according to the instability osteotomy was performed. In the high hip center cases, original hip center was reconstructed. Shortening length was determined not to make leg elongation more than 3cm. ModulusR were used for the replacement and fixation of the osteotomy.Introduction
Methods
Infection is one of the most severe comlications of the total arthroplasty. We sometimes encounter cases, which are very hard to finish repeated recurrence. Usage of steroids, immunosuppressants, and biologics would possibly effect to the incidence of the prosthetic infection and to the result of its treatment. Biologics have drastically decreased the number of the total arthoplasic patients, on the other hand, we must be more careful about the infectious conditions. For the infection two stage revision surgery; first removal and antibiotics cement spacer insertion then reimplantation later; is often chosen but sometimes one time antibiotics cement spacer cannot stop the infection and requires multi times spacer insertion. In those cases the dead spaces, poor blood supply and tight skin could be the cause of the recurrence. For these cases we had been performing musclo-cutaneal flap and successfully finish the infection. Our objectives are to review infection cases treated with musclo-cutaneal flap and compare with treatment without it. Methods: Since 2004 to 2013, 6 infection cases were treated. Our standard policy is 2-staged revision. In the first surgery, the prosthesis was removed and cement spacer was inserted. If no evidence of the remained infection was found reimplantation would be done in the second surgery. Otherwise debridement and cement spacer were repeated. In 3 cases, the infection could be finished without musclo-cutaneal flap but in 3 cases musclo-cutaneal flap was finally done then the infection was finished. The clinical courses were reviewed.Background
Objectives
Cementless short stems have the advantages of easy insertion, reduced thigh pain and being suitable for minimally-invasive surgery, therefore cementless short stem implants have been becoming more widely used. The revelation microMAX stem is a cementless short stem with a lateral flare design that allows for proximal physiological load transmission and more stable initial fixation. Images acquired with T-smart tomosynthesis using a new image reconstruction algorithm offer reduced artifacts near metal objects and clearer visualization of peri-implant trabeculae. Therefore, these images are useful for confirming implant fixation status after total hip arthroplasty (THA). We believe that T-smart tomosynthesis is useful for estimating the condition of microMAX stem fixation and will hereby report on observation of the postoperative course of microMAX stem. Subjects comprised 19 patients (20 hips) who underwent THA using micro MAXstem between July 2012 and November 2014 (males: 7, females: 12, mean age: 67 years, ranging from 38 to 83 years). Four patients had femoral head necrosis and 15 patients had osteoarthritis of the hip. All patients continuously underwent anterior-posterior and lateral view X-ray examination and an anterior-posterior T-smart tomosynthesis scan after the operations.Background
Materials and Methods
Since 1989, we have been developing lateral flare stem. The concept of lateral flare stem is to deliver proximal part big enough to fill the proximal cavity that most of the cement stems can fill and most of the cementless stems cannot. Also having distal part polished, much less distal load transfer occurs than cement stem. Thus, we can expect high proximal load transfer to prevent stress shielding. To deliver lateral flare stem, straight insertion path cannot be available, as proximal lateral part to fill inside the greater throchanter collides to the greater trochanter. So 3-Dimension insertion path was calculated to deliver that part through the narrow made by neck osteotomy. The first generation of the lateral flare stem was custom made. The second generation was designed as an off-the-shelf stem from what we have learned by the experience of custom stems. With the third generation, the stem was shortened to achieve more proximal load transfer. Direct Anterior Approach (DAA) developed by Judet is one of less invasive hip approach. With a stem with straight insertion path, the extended line of proximal femoral axis should come out of the skin. To achieve this position, proximal end of the femur has to be fully pulled up. (Fig.1) Some of the cases would be able to be lifted up but some have difficulty. Using lateral flare stem with curved 3 dimensional insertion path, even the axis extension does not come out of the skin, it would be expected to be inserted. In the present study, 3D insertion path of the lateral flare short stem for DAA was analyzed. Preoperative CAT scan data were transferred to STL data by Mimics®. The procedures after that were done by Magics®. First, neck osteotomy was done, externally rotated, and mild extension that doesn't make the axis come out of the skin was added. Then insertion path was verified keeping the stem attached medial sidewall of the canal (Fig. 2). In actual case, skin translation and pelvis rotation was assessed by 3D scanner. (Fig. 3)Introduction
Materials and methods
During THA in lateral position, keeping accurate lateral position is very important for obtaining good cup position. We normally use two kinds of hip positioner, but sometimes we can only use universal positioner provided with operational table. The pelvic tilt can be changed by surgical procedures such as traction, dislocation, reduction and so forth. In the present study, pre-op and post-op pelvic tilt was assessed using Kinect (Xbox 360′s sensor) as 3D scanner. As a 3D scanner, “Kinect®” was used (Fig. 1) with scanning software “Artec Studio 9 ®”. First, accuracy of the scanning system was validated, then 6 postero-lateral approach hip replacement with lateral position surgery cases (Fig.2) (1 male and 5 female, average 55.5 y.o., average BMI 27.6, IMP® positioner: 3 cases, Kyocera positioner: 2 cases, universal fixator provided with surgical table: 1 case), one direct anterior approach case, and one supine antero lateral case (Fig. 3) were scanned pre and post operatively. Pelvic tilts were assessed using tableside rails or edges of positioner that is tightly fixed to the table, as the reference.Introduction
Materials and Methods
This study shows the radiographic results of total hip arthroplasty (THA) using the Revelation hip system® for hip joint disease. We performed THA for hip disease using the Revelation Hip System®. From July 2007 to May 2009, 30cases (35 hips) were available for this study. Radiographic evaluation was performed at the last follow-up. Evaluation items included the presence or absence of subsidence, spot welds, demarcation line, cortical hypertrophy and stress shielding. The stem was designed to be implanted without cement and to be combined to the femur bone at the proximal portion to avoid stress shielding. Zone of Gruen zone 1 was divided into 1A or 1B, above and below the outermost tip of the lateral flare of the stem.Objective
Methods
In THA of DDH cases, sometimes shortening and/or derotational subtrochanteric osteotomy is required, for cases with high hip center and/or high anteversion. Initial fixation is one of the most important problems after subtrochanteric osteotomy. To prevent rotational displacement V-osteotomy or step osteotomy is often used. Even though until the osteotomy part unites, additional fixation is required. When a stem with distal load transfer was used body weight can be transferred to healthy part, so early full weight bearing should be expected. However, the muscles around hip joint can pull up proximal part, so it would be possible osteotomy part to be split. When a stem with proximal load transfer, body weight would be loaded on non united osteotomy part. So full weight bearing could sometimes be postponed. A stem that has both proximal and distal load transfer, and has facility for prevent rotation, those situations would possibly be simply solved. Lima (Italy) has a proximal load transfer conical stem with fins “Modulus” and a distal load transfer conical stem “Revision.” Combining these two stems, a stem as explained prior was designed. In the present study, applicability of the stem for cases such as subtrochanteric osteotomy was assessed. The stem geometry data were provided by the maker. Forty CAT scan DICOM data, 12 male, 28 female, 58+/−13.8 Y.O. were transferred to STL geometry data using Mimics®. Then using Magics® fit studies were done. For each femur, most suitable size of conventional “Modulus” and double conical stem “Modulus R” were selected to have tight fit making greater trochanter top height as head center height, then the area where stem core attaches to the inside surface of the canal were determined.Introduction
Materials and Methods
Patient specific surgical guide (PSSG) is a relatively new technique for accurate total knee arthroplasty (TKA), and there are many reports supporting PSSG can reduce the rate of outlier in the coronal plane. We began to use PSSG provided by Biomet (Signature®) and have reported the same results. Before using Signature, we performed TKA by modified gap technique (parallel cut technique) to get the well balanced flexion gap. Signature is the one of the measured resection technique using the anatomical landmarks as reference points on the images of CT or MR taken before surgery. We usually measure the center gap width and gap balance during operation with the special device “knee balancer”(Fig. 1) that can be used on patella reposition. After cutting all of the bone with Signature, gap balance in the extension position was very good but the gap balance was shown slight lateral opening in the 90 degrees flexion position. So we have changed the surgical procedure. We use Signature for cutting only distal femur and proximal tibia to get extension gap and apply the modified gap technique to decide the rotation of the femoral component (Signature with modified gap technique). The purpose of this study is to compare the gap balance between the two techniques. From November, 2012 through March, 2014, 50 CR type TKA (Vanguard Knee®, Biomet) in osteoarthritis patients were performed using Signature. 25 TKA were performed using only Signature (group S) and other 25 TKA were done using Signature with modified gap technique (group SG). After all osteotomies of femur and tibia were completed, applying femoral trial, center gap width and gap balance (plus means lateral opening angle) were measured using knee balancer with respect to 30 degrees of the knee flexion angle from zero to 120 degrees (Fig. 2).Introduction
Materials & Methods
According to Bipolar Hemiarthroplasty of the Hip (BHA), several reports indicated earlier acquisition of walking ability in direct anterior approach (DAA) than posterior approach (PA), but there is still few randomized studies comparing accuracy of stem insertion in DAA and PA. Therefore, we performed a prospective study, focusing positioning of implant. We chose 29 patients for this study, diagnosed as femoral neck fracture (Garden grade III or IV) from April 2012 to April 2013, excluding obesity patients (body mass index upper than 30kg/m2), muscular patients, osteoporotic patients (Sigh grade I or II), and tumor bearing patients. Patients were enrolled in a prospective, non-blinded study and were randomly assigned by envelope method to receive either DAA or PA. Taperloc BHA system (Zimmer) was adapted for all cases. Patient condition, operation condition and radiographic findings were investigated. On CT imaging, Canal fill was calculated Stem fill was studied at lower point of lesser trochanter that was considered to be load center. Static analysis was carried out using SPSS ver21 (IBMc). Continuous variables between the two groups were compared using a no matched bilateral Student's Purpose
Patient and Methods
Bi-plane Image matching method is very useful technique to evaluate the loaded 3D motion of each cervical level. Cervical orthoses are commonly used to regulate the motion of cervical spines for conservative treatment of injuries and for post-operative immobilization. Previous studies have reported the efficacy of orthoses for 2D flex-extension or 3D motions of the entire cervical spine. However, the ability of cervical orthoses to reduce motion might be different at each intervertebral level and for different types of motion (flexion-extension, rotation, lateral bending). The effectiveness of immobilizing orthoses at each cervical intervertebral level for 3D motions has not been reported. The purpose of this study is to evaluate the effectiveness of the Philadelphia collar to each level of cervical spines with 3D motion analysis under loading condition.Summary
Introduction
Cervical orthoses are commonly used to regulate the motion of cervical spines for conservative treatment of injuries and for post-operative immobilization. Previous studies have reported the efficacy of orthoses for 2D flex-extension or 3D motions of the entire cervical spine. However, the ability of cervical orthoses to reduce motion might be different at each intervertebral level and for different types of motion (flexion-extension, rotation, lateral bending). The effectiveness of immobilizing orthoses at each cervical intervertebral level for 3D motions has not been reported. The purpose of this study is to evaluate the effectiveness of the Philadelphia collar to each level of cervical spines with 3D motion analysis under loading condition.
Introduction
Patients & Methods
Obesity is one of the biggest issues to harm health so as increase medical costs worldwide. Unfortunately, Japan is no exception. Under a big governmental campaign, obese rate in Japanese elderly begins to decrease very recently. However, we cannot help to have impression that our patients who undergo hip/knee replacement surgery have been getting heavier and heavier. The purpose of this study is to examine the change of body mass in our patients and find related factors. We reviewed hospital record of patients who underwent knee or hip replacement from January 1 to December 31 in 2004 or 2012. Patient who underwent either unicompartmental or total knee arthroplasty was included, however, those who went through femoral head replacement (hemiarthroplasty) was excluded from this study population. Body mass index (BMI) was calculated from body height and weight measured within a week before surgery. Unlike in United States, BMI greater than 25 is categorized as obese, and below 18.5 is considered underweight in Japan. Additionally, gender, age at surgery, operated site (hip or knee), primary surgery or revision, blood loss in operation, surgery time, anesthesia time were evaluated as co-factors.Introduction:
Patients and methods:
We have been developed lateral flare stem and have been using it since 1989. It was custom stem at first. After being experienced, using the same software, off-the-shelf version lateral flare stem (Revelation) was developed in 1996 in the U.S. We could start using it since 2001 in our country. Lateral flare stems are designed to reproduce physiological proximal load transfer lateral side as well as medial side. It was obtained by having bigger and more accurate proximal part with lateral flare. The design is optimized by matching with 3D insertion path. Using many custom stems including different length and off-the-shelf standard stems, we have come to feel that as for this high proximal fit and load transfer design, it is not necessary to having long distal part and sometimes it is harmful to obtain good proximal load transfer in some situation such as type A (champagne flute) canal. So we have developed short version of the stem. Many makes of the hip stems have included short stems recently. Some aimed to improve easier insertion, some aimed to improve the volume of residual bone quantity. We have aimed to improve proximal fit expecting more proximal and more physiological load transfer to the femur. Our objectives are to comare standard stem and short stem from biomechanical aspect and clinical aspect.Introduction
Objectives
Massive defect of the acetabular bone is one of the severe situation in the hip arthroplasty. Installation of cup supporter or acetabular reinforcement device is one of the important method as well as big cup and bone graft etc. Preparing the device to be suitable shape is very important and installing it at the very position where the shaping was intended is also very important to obtain a stable condition for the arthroplasty. When we use navigation system, the device must be programmed in. But it is impossible to programme a device we have bended by ourselves into the system. If we can use a navigation system for such devices for those cases, we can expect better installation. We can fit the device on the patient's bone during the surgery of course; which is the ordinary procedure fot it; but it requires much time and tissue damage maybe with less accurate fitting. Two primary and three revision total hip arthroplasty cases with severe acetabular bone defect were treated with this method. First we have made chemical wood model for each case and bended the cup supporter on it. (Fig. 1) Then CAT scan of the model and the bended device on it were taken. Then the coordinate system of DICOM data set of the patient's original pelvis and the second DICOM data set i.e. the bended prosthesis were unified using MIMICS (Materialize, Belgium.) An STL format geometry data file of the bended device was extracted and merged into original DICOM dataset. Thus we could obtain a DICOM data set we call “predicted post-op DICOM.” During the surgery, a navigation system was used based on the predicted DICOM data.Introduction
Materials and Methods
This study shows the radiographic results of total hip arthroplasty (THA) using Revelation stem ® (Djo surgical USA) for hip joint disease. We removed cases which we couldn't follow up, the remaining of the patients who had undergone a primary THA July 2007 to December 2009 in our institution using Revelation hip stem® and 58 cases-65 hips (14 men and 44 women) were possible for progress observation on this study, and radiographic evaluation was done at the time of the last observation. The preoperative diagnosis of the hip included osteoarthritis (OA) in 40 patients, idiopatic, necrosis of the hip in 13 patients, Rheumatoid arthritis (RA) in 4 patients, and femoral head fracture in 1 patient. Three patients had undergone femoral head replacement (FHA) and 55 patients had undergone THA. At the time of the last evaluation, spot welds were detected in 63 hips (97%) in zone1 and 7. Demarcation lines, which indicates movement of the stem, were detected in zone3,4,5, but not in the proximal of the stem. Stress shielding were observed in 32 joints, according to Engh's classification, first degree were 27 joints and second degree were 5 joints. Cortical hypertrophy were detected in 13 joints. The revelation stem features a lateral overhang structure (lateral flare) and the stem has an expanded proximal geometry allowing the device to rest on both medial and lateral cortices at the metaphyseal level. Above all the stem has anterior overhand structure (trapezoidal structure). The medullary cavity occupation rate is made to increase by these structures. Above all, the stability of the stem is increased by a proximal portion by three point support. The distal stem is tapered and polished, which prevents the stress loading to a distal portion of the device. Stress shielding more than the third degree is not detected, and spots welds were detected in the proximal of the stem. These facts indicate that the concept of this stem, transmit loading to the femur bone, at the proximal portion of the stem, would be achieved.
In total hip arthroplasty, preoperative planning is almost indispensable. Moreover, 3-dimensional preoperative planning became popular recently. Anteversion management is one of the most important factors in preoperative planning to prevent dislocation and to obtain better function. In arthritic hip patients osteophytes are often seen on both femoral head and acetabulum. Especially on femoral head, osteophytes are often seen at posterior side and its surface creates smooth round contour that assumes new joint surface. (Fig. 1). We can imagine new femoral head center tracing that new joint surface. In the present study, the posterior osteophytes are compared in osteoarthritic patients and other patients.INTRODUCTION
OBJECTIVES
A Finite Element Analysis (FEA) is often used to examine load transfer between prosthesis and canal. Ordinary, bone elements' type is defined as elastic material. But using this element type for FEA on stem load transfer, the stems will jump out and fly away when the load is removed even friction between the stem and the canal was defined. This is remarkably different from the reality. It happens because the canal elements return to the original shape without the load. But actually, the bone is impacted by the load without returning to the original shape. Meshing the trabecular bone with a collapsible element type, it can collapse and be hardened by the stem pressure. We have been using Revelation (DJO, USA) with lateral flare for the primary cases whom we can expect high proximal load transfer. We were going to shorten its length to secure proximal load. We have been using Modulus (Lima Corporate, Italy) with conical fixation for the cases we expect mid stem load transfer and neck modification. We were going to extend its length for wider load transfer area. To examine load transfer of the designs the collapsible FEA was used. Our objectives are to examine load transfer between stems with different length and canal by collapsible FEA.Introduction
Objectives
Dislocation after total hip arthroplasty (THA) is one of the most serious complications. We recently modified the design of Lateral Flare femoral component (RevelationV2) with six degrees lower anteversion to reproduce the normal hip condition in Japanese. In addition, we added 10-degree slope on the posterior neck to prevent dislocation especially aimed to high anteversion cases. The purpose of this study is to verify the clinical outcome after this design modification. Hospital records and database were retrospectively reviewed. We investigated 46 consecutive hips in 43 patients who underwent primary total hip arthroplasty using RevelationV2 from September 2007 to August 2009. All patients implicated preoperative planning using CAT scan with their informed consents. The mean age and BMI at surgery were 63 years old and 23.1. Preoperative diagnosis was osteoarthritis (40/46: 87%), rheumatoid arthritis (2/46: 4%) or avascular necrosis of femoral head (4/46: 9%). There were 41 hips (89.2%) of Crowe I, 3(6.5%) of Crowe II and 2(4.3%) of Crowe III. Preoperative femoral neck anteversion averaged 28 degrees, whereas postoperative combined anteversion (the sum of femoral neck anteversion and anterior cup inclination) averaged 46 degrees. During follow up, 5 complications, in details, 3 mild peroneal nerve palsy, 1 pulmonary embolism and 1 dislocation following deep infection were reported. In conclusion, although no ordinal dislocation was found in this series, longer observation will need to judge appropriateness of this new component.
