Metal Artifact Reduction in Pelvic Computed Tomography With Hip Prostheses: Comparison of Virtual Monoenergetic Extrapolations From Dual-Energy Computed Tomography and an Iterative Metal Artifact Reduction Algorithm in a Phantom Study.

OBJECTIVE The aim of this study was to directly compare metal artifact reduction (MAR) of virtual monoenergetic extrapolations (VMEs) from dual-energy computed tomography (CT) with iterative MAR (iMAR) from single energy in pelvic CT with hip prostheses. MATERIALS AND METHODS A human pelvis phantom with unilateral or bilateral metal inserts of different material (steel and titanium) was scanned with third-generation dual-source CT using single (120 kVp) and dual-energy (100/150 kVp) at similar radiation dose (CT dose index, 7.15 mGy). Three image series for each phantom configuration were reconstructed: uncorrected, VME, and iMAR. Two independent, blinded radiologists assessed image quality quantitatively (noise and attenuation) and subjectively (5-point Likert scale). Intraclass correlation coefficients (ICCs) and Cohen κ were calculated to evaluate interreader agreements. Repeated measures analysis of variance and Friedman test were used to compare quantitative and qualitative image quality. Post hoc testing was performed using a corrected (Bonferroni) P < 0.017. RESULTS Agreements between readers were high for noise (all, ICC ≥ 0.975) and attenuation (all, ICC ≥ 0.986); agreements for qualitative assessment were good to perfect (all, κ ≥ 0.678). Compared with uncorrected images, VME showed significant noise reduction in the phantom with titanium only (P < 0.017), and iMAR showed significantly lower noise in all regions and phantom configurations (all, P < 0.017). In all phantom configurations, deviations of attenuation were smallest in images reconstructed with iMAR. For VME, there was a tendency toward higher subjective image quality in phantoms with titanium compared with uncorrected images, however, without reaching statistical significance (P > 0.017). Subjective image quality was rated significantly higher for images reconstructed with iMAR than for uncorrected images in all phantom configurations (all, P < 0.017). CONCLUSIONS Iterative MAR showed better MAR capabilities than VME in settings with bilateral hip prosthesis or unilateral steel prosthesis. In settings with unilateral hip prosthesis made of titanium, VME and iMAR performed similarly well.

Management of pelvic discontinuity in revision total hip arthroplasty: a review of the literature

Pelvic discontinuity is a complex problem in revision total hip arthroplasty. Although rare, the incidence is likely to increase due to the ageing population and the increasing number of total hip arthroplasties being performed. The various surgical options available to solve this problem include plating, massive allografts, reconstruction rings, custom triflanged components and tantalum implants. However, the optimal solution remains controversial. None of the known methods completely solves the major obstacles associated with this problem, such as restoration of massive bone loss, implant failure in the short- and long-term and high complication rates. This review discusses the diagnosis, decision making, and treatment options of pelvic discontinuity in revision total hip arthroplasty.

In silico methods to evaluate Fracture Risk and Bone Mineral Density changes in patients undergoing Total Hip Replacement

La sostituzione totale d’anca è uno degli interventi chirurgici con le più alte percentuali di successo. Esistono due varianti di protesi d’anca che differiscono in base al metodo di ancoraggio all’osso: cementate (fissaggio tramite cemento osseo) e non cementate (fissaggio tramite forzamento). Ad oggi, i chirurghi non hanno indicazioni quantitative di supporto per la scelta fra le due tipologie di impianto, decidendo solo in base alla loro esperienza. Due delle problematiche che interessano le protesi non cementate sono la possibilità di frattura intra-operatoria durante l’inserimento forzato e il riassorbimento osseo nel periodo di tempo successivo all’intervento. A partire da rilevazioni densitometriche effettuate su immagini da TC di pazienti sottoposti a protesi d’anca non cementata, sono stati sviluppati due metodi: 1) per la valutazione del rischio di frattura intra-operatorio tramite analisi agli elementi finiti; 2) per la valutazione della variazione di densità minerale ossea (tridimensionalmente attorno alla protesi) dopo un anno dall’operazione. Un campione di 5 pazienti è stato selezionato per testare le procedure. Ciascuno dei pazienti è stato scansionato tramite TC in tre momenti differenti: una acquisita prima dell’operazione (pre-op), le altre due acquisite 24 ore (post 24h) e 1 anno dopo l’operazione (post 1y). I risultati ottenuti hanno confermato la fattibilità di entrambi i metodi, riuscendo inoltre a distinguere e a quantificare delle differenze fra i vari pazienti. La fattibilità di entrambe le metodologie suggerisce la loro possibilità di impiego in ambito clinico: 1) conoscere la stima del rischio di frattura intra-operatorio può servire come strumento di guida per il chirurgo nella scelta dell’impianto protesico ottimale; 2) conoscere la variazione di densità minerale ossea dopo un anno dall’operazione può essere utilizzato come strumento di monitoraggio post-operatorio del paziente.

The Influence of Inert Packaging on the shelf Ageing of Gamma-Irradiation Sterilised ultra-high molecular weight polyethylene

Ultra-high molecular weight polyethylene (UHMWPE) is used for wear applications in total hip prostheses and total knee prostheses. Sterilisation of these prostheses is commonly by gamma-irradiation. This process creates reactive free radicals in the UHMWPE, greatly increasing its susceptibility to oxidative degradation. This study has investigated the influence of air and vacuum packaging on the properties of gamma-irradiated UHMWPE (GUR1050) following 3 years of shelf ageing. The findings indicate that vacuum packaging minimises oxidative degradation reactions that occur for UHMWPE during shelf ageing. However, gamma-irradiation of vacuum-packaged UHMWPE promotes a degree of cross-linking. It is proposed that this may enhance the wear performance of UHMWPE. Accelerated ageing studies indicate that 3 years of shelf ageing would also seem to reduce the susceptibility of gamma-irradiated UHMWPE to oxidative degradation upon removal from its vacuum packaging.

Multi-body simulation of a canine hind limb: model development, experimental validation and calculation of ground reaction forces

Background: Among other causes the long-term result of hip prostheses in dogs is determined by aseptic loosening. A prevention of prosthesis complications can be achieved by an optimization of the tribological system which finally results in improved implant duration. In this context a computerized model for the calculation of hip joint loadings during different motions would be of benefit. In a first step in the development of such an inverse dynamic multi-body simulation (MBS-) model we here present the setup of a canine hind limb model applicable for the calculation of ground reaction forces. Methods: The anatomical geometries of the MBS-model have been established using computer tomography- (CT-) and magnetic resonance imaging- (MRI-) data. The CT-data were collected from the pelvis, femora, tibiae and pads of a mixed-breed adult dog. Geometric information about 22 muscles of the pelvic extremity of 4 mixed-breed adult dogs was determined using MRI. Kinematic and kinetic data obtained by motion analysis of a clinically healthy dog during a gait cycle (1 m/s) on an instrumented treadmill were used to drive the model in the multi-body simulation. Results and Discussion: As a result the vertical ground reaction forces (z-direction) calculated by the MBS-system show a maximum deviation of 1.75%BW for the left and 4.65%BW for the right hind limb from the treadmill measurements. The calculated peak ground reaction forces in z- and y-direction were found to be comparable to the treadmill measurements, whereas the curve characteristics of the forces in y-direction were not in complete alignment. Conclusion: In conclusion, it could be demonstrated that the developed MBS-model is suitable for simulating ground reaction forces of dogs during walking. In forthcoming investigations the model will be developed further for the calculation of forces and moments acting on the hip joint during different movements, which can be of help in context with the in silico development and testing of hip prostheses.

Variation in age and physical status prior to total knee and hip replacement surgery : a comparison of centers in Australia and Europe

Objective : To investigate whether variation exists in the preoperative age, pain, stiffness, and physical function of people undergoing total knee replacement (TKR) and total hip replacement (THR) at several centers in Australia and Europe.
Methods : Individual Western Ontario and McMaster Universities Osteoarthritis Index data (range 0-100, where 0 = best and 100 = worst) collected within 6 weeks prior to primary TKR and THR were extracted from 16 centers (n = 2,835) according to specified eligibility criteria. Analysis of covariance was used to evaluate differences in pain, stiffness, and physical function between centers, with adjustment for age and sex.
Results : There was marked variation in the age of people undergoing surgery between the centers (TKR mean age 67-73 years; F[6,1004] = 4.21, P < 0.01, and THR mean age 63-72 years; F[14,1807] = 7.27, P < 0.01). Large differences in preoperative status were observed between centers, most notably for pain (TKR adjusted mean pain 52.5-61.1; F[6,1002] = 4.26, P < 0.01, and THR adjusted mean pain 49.2-65.7; F[14,1802] = 8.44, P < 0.01) and physical function (TKR adjusted mean function 52.7-61.4; F[6,1002] = 5.27, P < 0.01, and THR adjusted mean function 53.3-71.0; F[14,1802] = 6.71, P < 0.01). Large effect sizes (up to 0.98) reflect the magnitude of variation between centers and highlight the clinical relevance of these findings.
Conclusion : The large variations in age and preoperative status indicate substantial differences in the timing of joint replacement across the centers studied, with potential for compromised surgical outcomes due to premature or delayed surgery. Possible contributing factors include patient preferences, the absence of concrete indications for surgery, and the capacity of the health care systems.

Simulação numérica através do método dos elementos finitos e comparação experimental para obtenção de tensões e deformações específicas em fêmur com prótese total de quadril

Pós-graduação em Engenharia Mecânica - FEG

Desenvolvimento de um equipamento para análise de desgastes em prótese de articulação total de quadril

Pós-graduação em Engenharia Mecânica - FEG

Simultaneous bilateral hip replacement reveals superior outcome and fewer complications than two-stage procedures: a prospective study including 1819 patients and 5801 follow-ups from a total joint replacement registry

Background Total joint replacements represent a considerable part of day-to-day orthopaedic routine and a substantial proportion of patients undergoing unilateral total hip arthroplasty require a contralateral treatment after the first operation. This report compares complications and functional outcome of simultaneous versus early and delayed two-stage bilateral THA over a five-year follow-up period. Methods The study is a post hoc analysis of prospectively collected data in the framework of the European IDES hip registry. The database query resulted in 1819 patients with 5801 follow-ups treated with bilateral THA between 1965 and 2002. According to the timing of the two operations the sample was divided into three groups: I) 247 patients with simultaneous bilateral THA, II) 737 patients with two-stage bilateral THA within six months, III) 835 patients with two-stage bilateral THA between six months and five years. Results Whereas postoperative hip pain and flexion did not differ between the groups, the best walking capacity was observed in group I and the worst in group III. The rate of intraoperative complications in the first group was comparable to that of the second. The frequency of postoperative local and systemic complication in group I was the lowest of the three groups. The highest rate of complications was observed in group III. Conclusions From the point of view of possible intra- and postoperative complications, one-stage bilateral THA is equally safe or safer than two-stage interventions. Additionally, from an outcome perspective the one-stage procedure can be considered to be advantageous.

Surgical treatment approaches and reimbursement costs of surgical site infections post hip arthroplasty in Australia : a retrospective analysis

BACKGROUND: The treatment for deep surgical site infection (SSI) following primary total hip arthroplasty (THA) varies internationally and it is at present unclear which treatment approaches are used in Australia. The aim of this study is to identify current treatment approaches in Queensland, Australia, show success rates and quantify the costs of different treatments. METHODS: Data for patients undergoing primary THA and treatment for infection between January 2006 and December 2009 in Queensland hospitals were extracted from routinely used hospital databases. Records were linked with pathology information to confirm positive organisms. Diagnosis and treatment of infection was determined using ICD-10-AM and ACHI codes, respectively. Treatment costs were estimated based on AR-DRG cost accounting codes assigned to each patient hospital episode. RESULTS: A total of n=114 patients with deep surgical site infection were identified. The majority of patients (74%) were first treated with debridement, antibiotics and implant retention (DAIR), which was successful in eradicating the infection in 60.3% of patients with an average cost of $13,187. The remaining first treatments were 1-stage revision, successful in 89.7% with average costs of $27,006, and 2-stage revisions, successful in 92.9% of cases with average costs of $42,772. Multiple treatments following 'failed DAIR' cost on average $29,560, for failed 1-stage revision were $24,357, for failed 2-stage revision were $70,381 and were $23,805 for excision arthroplasty. CONCLUSIONS: As treatment costs in Australia are high primary prevention is important and the economics of competing treatment choices should be carefully considered. These currently vary greatly across international settings.