The role of bone remodeling in measuring migration of custom implants for large acetabular defects.

In revision total hip arthroplasty, achieving robust fixation is difficult and implant movement may occur over time. Bone may also rearrange around the implant as a result of mechanical loading, making the measurement of migration challenging. The study aimed to quantify changes in bone shape and implant position 1 year following acetabular reconstruction using custom three-dimensional-printed cups. This observational retrospective cohort study involved 23 patients with Paprosky type IIIB defects. Postop computed tomography scans taken within 1 week of surgery and at 1-year postsurgery were co-registered and analyzed. Three co-registration strategies were implemented including bone-to-bone and implant-to-implant. (1) Co-registration of the ipsilateral innominate bone (diseased anatomy) was used to measure changes in implant position. (2) Co-registration of the implant was carried out to quantify changes in the ipsilateral innominate bone shape. (3) Co-registration of the contralateral innominate bone (nondiseased anatomy) was performed to measure changes in the ipsilateral innominate bone shape and implant position. The median centroid distances (interquartile range [IQR]) were 2.3 mm (IQR: 3.7-1.7 mm) for changes in implant position, 2.4 mm (IQR: 3.6-1.6 mm) for changes in ipsilateral innominate bone shape, and 3.7 mm (IQR: 4.6-3.5 mm) for changes in ipsilateral innominate bone shape and implant position. Following acetabular reconstruction, implant movements and periprosthetic bone remodeling are physiological and of a similar extent. Surgeons and engineers should consider this when performing implant monitoring in these patients.

Cemented or uncemented fixation: Which allows a more acceptable prosthetic femoral version in total hip arthroplasty?

BACKGROUND: Three-dimensional computed-tomography (3D-CT) planning for primary Total Hip Arthroplasty (THA) typically uses the external femoral surface; as a result, it is difficult to predict the prosthetic femoral version (PFV) for uncemented femoral stems that press-fit to the internal surface of the bone. Cemented fixation allows the surgeon to adjust the version independent of the internal femoral anatomy. We aimed to better understand the effect of the fixation type on PFV. METHODS: This was a case series study including a total of 95 consecutive patients (106 hips), who underwent uncemented (n = 81 hips) and cemented (n = 25 hips) primary THA using the posterior approach. The surgeon aimed for a PFV of 20°. Our primary objective was to compare PFV in both groups; our secondary objective was to evaluate the clinical outcomes. RESULTS: The mean (± SD) PFV was 13° (± 9°) and 23° (± 8°) for the uncemented and cemented THA groups (P < 0.001), respectively. In the uncemented THA group, 36% of the patients had a PFV of < 10°. In the cemented THA group, this clinically important threshold dropped to 8%. Similarly, the Bland-Altman (BA) plots showed wider 95% limits of agreement for the uncemented group. Satisfactory clinical outcomes were recorded. CONCLUSION: We found that the PFV was more clinically acceptable, for the posterior surgical approach, in the cemented group when compared to the uncemented group. Both THA groups reported high variability indicating the need to develop surgical tools to guide the PFV closer to the surgical target.

The variability of CT scan protocols for total hip arthroplasty: a call for harmonisation.

CT is the principal imaging modality used for the pre-operative 3D planning and assessment of total hip arthroplasty (THA). The image quality offered by CT has a radiation penalty to the patient. Higher than necessary radiation exposure is of particular concern when imaging young patients and women of childbearing age, due to the greater risk of radiation-induced cancer in this group. A harmonised low-dose CT protocol is needed, evidenced by the huge variability in the 17 protocols reviewed. The majority of the protocols were incomplete, leading to uncertainty among radiographers when performing the scans. Only three protocols (20%) were optimised for both 'field of view' and image acquisition parameters. 10 protocols (60%) were optimised for 'field of view' only. These protocols included imaging of the relevant landmarks in the bony pelvis in addition to the knees - the reference for femoral anteversion. CT parameters, including the scanner kilovoltage (kV), milliamperage-time product (mAs) and slice thickness, must be optimised with a 'field of view' that includes the relevant bony landmarks. The recommended kV and mAs values were very wide ranging from 100 to 150 and from 100 to 250, respectively. The large variability that exists amongst the CT protocols illustrates the need for a more consistent low-dose CT protocol for the planning of THA. This must provide an optimal balance between image quality and radiation dose to the patient. Current CT scanners do not allow for measurements of functional pelvic orientation and additional upright imaging modalities are needed to augment them.

Gender similarities and differences in skeletal muscle and body composition: an MRI study of recreational cyclists.

Objectives: This study aims to quantitatively evaluate whether there are muscle mass differences between male and female recreational cyclists and compare muscle quality and body composition in the pelvis region between two well-matched groups of fit and healthy male and female adults. Methods: This cross-sectional study involved 45 female and 42 male recreational cyclists. The inclusion criteria for both groups were to have cycled more than 7000 km in the last year, have an absence of injuries and other health problems, have no contraindication to MRI, and be 30-65 years old. Our main outcome measures were fat fraction, as a measure of intramuscular fat (IMF) content, and volume of the gluteal muscles measured using Dixon MRI. The gluteal subcutaneous adipose tissue (SAT) volume was evaluated as a secondary measure. Results: We found that there were no gender differences in the IMF content of gluteus maximus (GMAX, p=0.42), gluteus medius (GMED, p=0.69) and gluteus minimus (GMIN, p=0.06) muscles, despite women having more gluteal SAT (p<0.01). Men had larger gluteal muscles than women (p<0.01), but no differences were found when muscle volume was normalised by body weight (GMAX, p=0.54; GMED, p=0.14; GMIN, p=0.19). Conclusions: Our study shows that despite the recognised hormonal differences between men and women, there is gender equivalence in the muscle mass and quality of the gluteal muscles when matched for exercise and body weight. This new MRI study provides key information to better understand gender similarities and differences in skeletal muscle and body composition.

Pin Fracture in Magnetically Controlled Growing Rods: Influence of the Year of Manufacture.

BACKGROUND: Magnetically controlled growing rods (MCGRs) have a known issue with fracture of the internal locking pin resulting in early revisions. The manufacturer reported that rods manufactured before March 26, 2015, had a 5% risk of locking pin fracture. Locking pins made after this date are thicker in diameter and of a tougher alloy; their rate of pin fracture is not known. The aim of this study was to better understand the impact of the design changes on the performance of MCGRs. METHODS: This study involves 46 patients with 76 removed MCGRs. Forty-six rods were manufactured before March 26, 2015, and 30 rods after that date. Clinical and implant data were collected for all MCGRs. Retrieval analysis comprised plain radiographs evaluations, force and elongation testing, and disassembly. RESULTS: The 2 patient groups were statistically comparable. We found that 14 of 27 patients implanted with rods manufactured before March 26, 2015 (group I) had a fracture of their locking pins. Three of the 17 patients with rods manufactured after this date (group II) were also found to have a fractured pin. CONCLUSIONS: Retrieved rods collected at our center and made after March 26, 2015, had far fewer locking pin fractures than those made before this date; this may be due to the change in pin design.

Custom 3D-Printed Implants for Acetabular Reconstruction: Intermediate-Term Functional and Radiographic Results.

The management of massive acetabular defects at the time of revision hip surgery is challenging. Severe pelvic bone loss and the heterogeneity and quality of the remaining bone stock can compromise the fixation and mechanical stability of the implant. Methods: We reviewed a database of consecutive patients who had undergone acetabular reconstruction with the use of a custom 3D-printed implant with a dual-mobility bearing for the treatment of Paprosky type-3B defects between 2016 and 2019. Functional and radiological outcomes were assessed. Results: A total of 26 patients (17 women and 9 men) with a minimum follow-up of 36 months (median, 53 months; range, 36 to 77 months) were identified. The median age at surgery was 69 years (range, 49 to 90 years), and 4 patients had pelvic discontinuity. The cumulative implant survivorship was 100%. The median Oxford Hip Score improved significantly from 8 (range, 2 to 21) preoperatively to 32 (range, 14 to 47) postoperatively (p = 0.0001). One patient had a transient sciatic nerve palsy, 1 hip dislocated 6 months postoperatively and was managed nonoperatively, and 1 infection recurred. No patient had a fracture. Radiographic evaluation showed bone ingrowth at the bone-implant interface in 24 patients (92%) at ≥12 months of follow-up and showed no evidence of implant loosening or migration at the latest follow-up (3 to 6 years). Conclusions: Excellent functional improvement, implant survivorship, and osseointegration were recorded in the patient cohort. Accurate preoperative planning and the adoption of custom 3D-printed implants showed promising results in complex revision hip surgery. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can version of the proximal femur be used for CT planning uncemented femoral stems?

Three-Dimensional Computed Tomography (3D-CT) planning can predict the prosthetic femoral size in uncemented primary Total Hip Arthroplasty (THA). Correct sizing usually results in optimal varus/valgus femoral alignment; however, its effect on the Prosthetic Femoral Version (PFV) is poorly understood. Most 3D-CT planning systems use Native Femoral Version (NFV) to plan PFV. We aimed to assess the relationship between PFV and NFV in primary uncemented THA using 3D-CT analysis. Pre- and post-operative CT data was retrospectively collected from 73 patients (81 hips) undergoing primary uncemented THA with a straight-tapered stem. 3D-CT models were used to measure PFV and NFV. The clinical outcomes were evaluated. The discrepancy between PFV and NFV was low (<5°) in 43%, moderate (5-10°) in 40%, high (10-15°) in 11% and very high (>15°) in 6% of the cases. We found that NFV is not a useable guide for planning PFV. The 95% limits of agreement were both high at 17° and 15°, respectively. Satisfactory clinical outcomes were recorded. The discrepancy was large enough to recommend against the use of NFV for planning PFV when using straight-tapered uncemented stems. Further work should focus on the internal bony anatomy and the influence of stem design when planning uncemented femoral stems.

The accuracy and precision of acetabular implant measurements from CT imaging.

The placement of acetabular implant components determines the short- and long-term outcomes of total hip replacement (THR) and a number of tools have been developed to assist the surgeon in achieving cup orientation to match the surgical plan. However, the accuracy and precision of 3D-CT for the measurement of acetabular component position and orientation is yet to be established. To investigate this, we compared measurements of cobalt chrome acetabular components implanted into 2 different bony pelvic models between a coordinate measuring Faro arm and 3 different low dose CT images, including 3D-CT, 2D anterior pelvic plane (APP) referenced CT and 2D scanner referenced (SR) CT. Intra-observer differences were assessed using the Intraclass correlation coefficient (ICC). The effect of imaging the pelvis positioned in 3 different orientations within the CT scanner was also assessed. The measured parameters were the angles of inclination and version. 3D-CT measurements were found to closely match the "true values" of the component position measurements, compared with the 2D-CT methods. ICC analysis also showed good agreement between the coordinate measuring arm (CMA) and 3D-CT but poor agreement between the 2D SR method, in the results from two observers. When using the coordinate system of the CT scanner, the measurements consistently produced the greatest error; this method yielded values up to 34° different from the reference digitising arm. However, the difference between the true inclination and version angles and those measured from 3D APP CT was below half a degree in all cases. We concluded that low radiation dose 3D-CT is a validated reference standard for the measurement of acetabular cup orientation.

Guiding prosthetic femoral version using 3D-printed patient-specific instrumentation (PSI): a pilot study.

BACKGROUND: Implantation of the femoral component with suboptimal version is associated with instability of the reconstructed hip joint. High variability of Prosthetic Femoral Version (PFV) has been reported in primary Total Hip Arthroplasty (THA). Three-dimensional (3D) Patient-Specific Instrumentation (PSI) has been recently developed and may assist in delivering a PFV within the intended range. We performed a pilot study to better understand whether the intra-operative use of a novel PSI guide, designed to deliver a PFV of 20°, results in the target range of PFV in primary cemented THA. METHODS: We analysed post-operative Computed-Tomography (CT) data of two groups of patients who underwent primary cemented THA through posterior approach; 1. A group of 11 patients (11 hips) for which the surgeon used an intra-operative 3D-printed stem positioning guide (experimental) 2. A group of 24 patients (25 hips) for which the surgeon did not use the guide (control). The surgeon aimed for a PFV of 20°, and therefore the guide was designed to indicate the angle at which the stem was positioned intra-operatively. PFV angles were measured using the post-operative 3D-CT models of the proximal femurs and prosthetic components in both groups. Our primary objective was to compare the PFV in both groups. Our secondary objective was to evaluate the clinical outcome. RESULTS: Mean (± SD) values for the PFV was 21.3° (± 4.6°) and 24.6° (± 8.2°) for the experimental and control groups respectively. In the control group, 20% of the patients reported a PFV outside the intended range of 10° to 30° anteversion. In the experimental group, this percentage dropped to 0%. Satisfactory clinical outcome was recorded in both groups. CONCLUSION: The intra-operative use of a PSI PFV guide helped the surgeon avoid suboptimal PFV in primary cemented THA. Further studies are needed to evaluate if the PSI guide directly contributes to a better clinical outcome.

Statistical shape modeling of the large acetabular defect in hip revision surgery.

The assessment of three-dimensional bony defects is important to inform the surgical planning of hip reconstruction. Mirroring of the contralateral side has been previously used to measure the hip center of rotation (CoR). However, the contralateral side may not be useful when diseased or replaced. Statistical Shape Models (SSMs) can aid reconstruction of patient anatomy. Previous studies have been limited to computational models only or small patient cohorts. We used SSM as a tool to help derive landmarks that are often absent in hip joints of patients with large acetabular defects. Our aim was to compare the reconstructed pelvis with patients who have previously undergone hip revision. This retrospective cohort study involved 38 patients with Paprosky type IIIB defects. An SSM was built on 50 healthy pelvises and used to virtually reconstruct the native pelvic morphology for all cases. The outcome measures were the difference in CoR for (1) SSM versus diseased hip, (2) SSM versus plan, and (3) SSM versus contralateral healthy hip. The median differences in CoR were 31.17 mm (interquartile range [IQR]: 43.80-19.87 mm), 8.53 mm (IQR: 12.76-5.74 mm), and 7.84 mm (IQR: 10.13-5.13 mm), respectively. No statistical difference (p > 0.05) was found between the SSM versus plan and the SSM versus contralateral CoRs. Our findings show that the SSM model can be used to reconstruct the absent bony landmarks of patients with significant lysis regardless of the defect severity, hence aiding the surgical planning of hip reconstruction and implant design.

Mid-life cyclists preserve muscle mass and composition: a 3D MRI study.

Physical activity and a healthy lifestyle are crucial factors for delaying and reducing the effects of sarcopenia. Cycling has gained popularity in the last decades among midlife men. While the cardiovascular benefits of cycling and other endurance exercises have been extensively proved, the potential benefits of lifelong aerobic exercise on muscle health have not been adequately studied. Our aim was to quantify the benefits of cycling in terms of muscle health in middle-aged men, using magnetic resonance imaging. We ran a cross-sectional study involving two groups of middle-aged male adults (mean age 49 years, range 30-65) that underwent Dixon MRI of the pelvis. The groups consisted of 28 physically inactive (PI) and 28 trained recreational cyclists. The latter had cycled more than 7000 km in the last year and have been training for 15 years on average, while the PI volunteers have not practiced sports for an average of 27 years. We processed the Dixon MRI scans by labelling and computing the fat fraction (FF), volume and lean volume of gluteus maximus (GMAX) and gluteus medius (GMED); and measuring the volume of subcutaneous adipose tissue (SAT). We found that the cyclists group had lower FF levels, a measure of intramuscular fat infiltration, compared to the PI group for GMAX (PI median FF 21.6%, cyclists median FF 14.8%, p < 0.01) and GMED (PI median FF 16.0%, cyclists median FF 11.4%, p < 0.01). Cyclists had also larger GMAX and GMED muscles than the PI group (p < 0.01), after normalizing it by body mass. Muscle mass and fat infiltration were strongly correlated with SAT volume. These results suggest that cycling could help preserve muscle mass and composition in middle-aged men. Although more research is needed to support these results, this study adds new evidence to support public health efforts to promote cycling.

Rod Fracture in Magnetically Controlled Growing Spine Rods.

BACKGROUND: The mechanisms of fracture in magnetically controlled growing rods (MCGRs) and the risk factors associated with this are poorly understood. This retrospective analysis of explanted MCGRs aimed to add understanding to this subject. METHODS: From our cohort of over 120 retrieved MCGRs, we identified 7 rods that had fractured; all were single-rod constructs, retrieved from 6 patients. These were examined and compared with 15 intact single-rod constructs. Retrieval and fractographic analyses were used to determine the failure mode at the fracture site and the implant's functionality. Cobb angle, degree of rod contouring, and the distance between anchoring points were computed on anteroposterior and lateral radiographs. RESULTS: 5/7 versus 3/15 rods had been inserted after the removal of a previously inserted rod, in the fractured versus control groups. All fractured rods failed due to bending fatigue. Fractured rods had greater rod contouring angles in the frontal plane ( P = 0.0407) and lateral plane ( P = 0.0306), and greater distances between anchoring points in both anteroposterior and lateral planes ( P = 0.0061 and P = 0.0074, respectively). CONCLUSIONS: We found all failed due to a fatigue fracture and were virtually all single rod configurations. Fracture initiation points corresponded with mechanical indentation marks induced by the intraoperative rod contouring tool. Fractured rods had undergone greater rod contouring and had greater distances between anchoring points, suggesting that it is preferable to implant double rod constructs in patients with sufficient spinal maturity to avoid this complication. CLINICAL RELEVANCE: Level III.

The analysis of defects in custom 3D-printed acetabular cups: A comparative study of commercially available implants from six manufacturers.

Three-dimensional (3D) printing is used to manufacture custom acetabular cups to treat patients with massive acetabular defects. There is a risk of defects occurring in these, often in the form of structural voids. Our aim was to investigate the presence of voids in commercially available cups. We examined 12, final-production titanium custom acetabular cups, that had been 3D-printed by six manufacturers. We measured their mass, then performed micro-computed tomography (micro-CT) imaging to determine their volume and density. The micro-CT data were examined for the presence of voids. In cups that had voids, we computed (1) the number of voids, (2) their volume and the cup volume fraction, (3) their sphericity, (4) size, and (5) their location. The cups had median mass, volume, and density of 208.5 g, 46,471 mm3 , and 4.42 g/cm3 , respectively. Five cups were found to contain a median (range) of 90 (58-101) structural voids. The median void volume and cup volume fractions of cups with voids were 5.17 (1.05-17.33) mm3 and 99.983 (99.972-99.998)%, respectively. The median void sphericity and size were 0.47 (0.19-0.65) and 0.64 (0.27-8.82) mm, respectively. Voids were predominantly located adjacent to screw holes, within flanges, and at the transition between design features; these were between 0.17 and 4.66 mm from the cup surfaces. This is the first study to examine defects within final-production 3D-printed custom cups, providing data for regulators, surgeons, and manufacturers about the variability in final print quality. The size, shape, and location of these voids are such that there may be an increased risk of crack initiation from them.

Accuracy of a Three-Dimensional (3D)-Printed Patient-Specific (PS) Femoral Osteotomy Guide: A Computed Tomography (CT) Study.

Femoral neck osteotomy creates a critical anatomical landmark for surgeons performing primary Total Hip Arthroplasty (THA); it affects the final height and position of the femoral component. Patient Specific Instrumentation (PSI) has been developed to guide the osteotomy. We aimed to assess the accuracy of a patient-specific (PS) femoral osteotomy guide in primary THA using three-dimensional (3D) computed tomography (CT) analysis. We included pre- and post-operative CT data of 103 THAs. All patients underwent 3D planning to define the optimal femoral neck osteotomy level. Our primary objective was to quantify the discrepancy between the achieved and planned osteotomy level; our secondary objective was to evaluate the clinical outcome. The median (Interquartile Range­IQR) discrepancy between the achieved and planned osteotomy level was 0.3 mm (−1 mm to 2 mm). We found a strong positive correlation between the planned and achieved osteotomy level (R2 = 0.9, p < 0.001). A satisfactory clinical outcome was recorded. Our findings suggest that surgeons can use 3D-printed PS guides to achieve a femoral neck osteotomy with a high level of accuracy to the plan.

Morphometric analysis of patient-specific 3D-printed acetabular cups: a comparative study of commercially available implants from 6 manufacturers.

BACKGROUND: 3D printed patient-specific titanium acetabular cups are used to treat patients with massive acetabular defects. These have highly porous surfaces, with the design intent of enhancing bony fixation. Our aim was to characterise these porous structures in commercially available designs. METHODS: We obtained 12 final-production, patient-specific 3D printed acetabular cups that had been produced by 6 manufacturers. High resolution micro-CT imaging was used to characterise morphometric features of their porous structures: (1) strut thickness, 2) the depth of the porous layer, (3) pore size and (4) the level of porosity. Additionally, we computed the surface area of each component to quantify how much titanium may be in contact with patient tissue. Statistical comparisons were made between the designs. RESULTS: We found a variability between designs in relation to the thickness of the struts (0.28 to 0.65 mm), how deep the porous layers are (0.57 to 11.51 mm), the pore size (0.74 to 1.87 mm) and the level of porosity (34 to 85%). One manufacturer printed structures with different porosities between the body and flange; another manufacturer had two differing porous regions within the body of the cups. The cups had a median (range) surface area of 756.5 mm2 (348 - 1724). CONCLUSIONS: There is a wide variability between manufacturers in the porous titanium structures they 3D print. We do not currently know whether there is an optimal porosity and how this variability will impact clinically on the integrity of bony fixation; this will become clearer as post market surveillance data is generated.

Blood titanium levels in patients with large and sliding titanium implants.

BACKGROUND: Titanium, which is known to be a highly biologically inert element, is one of the most commonly used metals in orthopaedic implants. While cobalt and chromium blood metal ion testing is routinely used in the clinical monitoring of patients with metal-on-metal hip implants, much less is known about the levels of titanium in patients with other implant types. The aim of this study was to better understand the normal ranges of blood titanium levels in patients implanted with large and sliding titanium constructs by comparison with reference levels from conventional titanium hips. METHODS: This study examined data collected from 136 patients. Over a period of 24 months, whole blood samples were collected from 41 patients implanted with large titanium implants: long (range 15 to 30 cm) spine rods with a sliding mechanism ("spine rods", n = 18), long bone tumour implants ("tumour implants", n = 13) and 3D-printed customised massive acetabular defect implants ("massive acetabular implants", n = 10). This data was compared with standard, uncemented primary titanium hip implants ("standard hips", 15 cm long) (n = 95). Clinical, imaging and blood titanium levels data were collected for all patients and compared statistically between the different groups. RESULTS: The median (range) of blood titanium levels of the standard hip, spine rods, femoral tumour implants and massive acetabular implants were 1.2 ppb (0.6-4.9), 9.7 ppb (4.0-25.4), 2.6 ppb (0.4-104.4) and 5.7 ppb (1.6-31.5) respectively. Spine rods and massive acetabular implants had significantly greater blood titanium levels compared to the standard hips group (p < 0.001). CONCLUSION: This study showed that titanium orthopaedic implants that are large and/or have a sliding mechanism have higher blood titanium levels compared to well-functioning, conventionally sized titanium hips. Reassuringly, the increased levels did not appear to induce adverse metal reactions. This study provides useful baseline data for future studies aimed at assessing blood titanium levels as a biomarker for implant function.

Comparative retrieval analysis of a novel anatomic tibial tray backside: alterations in tibial component design and surface coating can increase cement adhesions and surface roughness.

BACKGROUND: With the Persona® knee system a novel anatomic total knee design was developed, which has no pre-coating, whereas the predecessor knee system is pre-coated with polymethylmethacrylate (PMMA). Joint registry data have shown no decrease in risk of aseptic revision of PMMA pre-coated tibial components compared with non-pre-coated implants. The aim of this retrieval study was to compare the amount of cement adhesions, geometry and surface features between the two knee designs and to correlate them with the underlying reason for revision surgery. METHODS: Retrieval analysis was performed of 15 NexGen® and 8 Persona® fixed-bearing knee implants from the same manufacturer retrieved from two knee revision centres. A photogrammetric method was used to grade the amount of cement attached to the tibial tray backside. The geometry and dimensions of the tibial trays, tray projections and peripheral lips were measured using digital callipers and compared between the two different designs. To measure the surface roughness on the backside of the tibial tray, a contact profilometer was used. To investigate differences between the two designs statistical analyses (t-test) were performed. RESULTS: All Persona® trays showed evidence of cement adhesion with a % area of 75.4%; half of the NexGen® trays had cement adhesions, with a mean value of 20%. There was a significant difference in the percentage of area covered by cement between the two designs (p < 0.001). Results from the contact profilometer revealed that Persona® and NexGen® tray backsides showed a similar lateral (1.36 µm and 1.10 µm) and medial (1.39 µm and 1.12 µm) mean surface roughness with significant differentiation (p < 0.05) of the lateral and medial roughness values between the two designs. Persona® stems showed a significantly higher mean surface roughness (1.26) compared to NexGen® stems (0.89; p < 0.05). CONCLUSION: The novel anatomic knee system showed significantly more cements adhesions and a higher surface roughness which was most likely attributed to the most obvious design and coating alteration of the tibial tray. This study provides first retrieval findings of a novel TKA design recently introduced to the market.

SPECT/CT Assessment of In-Vivo Loading of the Knee Correlates with Polyethylene Deformation in Retrieved Total Knee Arthroplasty.

BACKGROUND: SPECT/CT distribution patterns in patients with total knee replacements have previously been correlated with factors such as time of implantation, implant type and alignment. It is unknown, however, if an increased and more extended bone tracer uptake (BTU) in SPECT/CT, representing loading of the joint, correlates with findings from retrieval studies. The aim of this study was to further understand this subject. MATERIALS AND METHODS: 62 retrieved TKA were included. SPECT/CT was performed prior to revision. Quantitative and qualitative medio-lateral comparisons of BTU intensity and distribution in the tibia were performed. Retrieval analysis was performed with a micro-CT method to assess the thickness differences between medial and lateral sides of polyethylene inserts with symmetrical designs. RESULTS: In the subgroup of TKA with asymmetrical SPECT/CT distribution, there was a significant correlation between retrieval and medical imaging data (p = 0.0355): patients showing a more extended BTU in the medial compartment also had a significantly thinner insert in the medial compartment, and vice versa in the lateral side. CONCLUSION: This is the first study comparing BTU distribution patterns and retrieval findings. Our results support the hypothesis that SPECT/CT is able to identify bone activity due to implant position and loading.

Self-Reported Neurotoxic Symptoms in Hip Arthroplasty Patients With Highly Elevated Blood Cobalt: A Case-Control Study.

OBJECTIVES: This study aimed to investigate the prevalence of self-reported neurotoxicity and cognitive defects in hip replacement patients with markedly raised blood cobalt. METHODS: Case group comprised 53 patients with metal-on-metal (MoM) implants and a history of blood Co ≥20 µg/L for a median of 3 years (interquartile range, 2-5 years). The control group comprised 53 patients with ceramic-on-ceramic prostheses and blood Co <1 µg/L. Median age was 67 years (interquartile range, 60-74 years). The participants completed the Neurotoxic Symptom Checklist-60, Diabetic Neuropathy Score, Douleur Neuropathique-10, and Systemic Symptom Checklist, and underwent the Mini-Mental State Examination. RESULTS: The MoM and ceramic-on-ceramic groups were compared, the results were as follows: Neurotoxic Symptom Checklist-60 (median): cognitive defects (2.0 versus 1.9; P = 0.002), chest complaints (1.3 versus 1.3; P = 0.042), balance disturbances (1.3 versus 1.0; P < 0.001), sleep disturbances (2.7 versus 2.0; P = 0.004), mood disorders (2.0 versus 1.5; P = 0.001), sensorimotor disorders (1.6 versus 1.2; P < 0.001), physical complaints (2.0 versus 1.4; P = 0.009), fatigue (2.0 versus 1.6; P = 0.001), and total score (108 versus 90; P < 0.001); abnormal Diabetic Neuropathy Score/Douleur Neuropathique-10 (%): 60.3/13.2 versus 24.5/1.9 (P < 0.001/P = 0.028). Systemic Symptom Checklist (in percent): feeling cold (37.7 versus 17; P = 0.01), weight gain (18.9 versus 1.9; P = 0.008), metallic taste (26.4 versus 3.8; P = 0.002), worsening eyesight (37.7 versus 15.1; P = 0.008) and hearing (24.5 versus 7.5; 0.032), ankle swelling (32.1 versus 7.5; P = 0.002), shortness of breath on exertion (9.4 versus 5.7; P = 0.015), and generalized rash (28.3 versus 7.5; P = 0.01); and Mini-Mental State Examination (median): 29 versus 30 (P = 0.017). Patients in the MoM group were aware of their high cobalt levels and displayed a higher tendency to overreport symptoms (P < 0.001), which could have contributed to the higher scores. CONCLUSIONS: Frequency of reporting a number of symptoms was markedly higher in MoM patients, but clinically significant neurotoxicity was not observed (possibly due to the short exposure to elevated cobalt). Patients with repeated blood Co ≥20 µg/L measurements should be questioned about possible systemic health complaints at follow-up.