Postoperative full leg radiographs exhibit less residual coronal varus deformity compared to intraoperative measurements in robotic arm-assisted total knee arthroplasty with the MAKO™ system.

PURPOSE: Robotic arm-assisted total knee arthroplasty (raTKA), currently a major trend in knee arthroplasty, aims to improve the accuracy of implant positioning and limb alignment. However, it is unclear whether and to what extent manual radiographic and navigation measurements with the MAKO™ system correlate. Nonetheless, a high agreement would be crucial to reliably achieve the desired limb alignment. METHODS: Thirty-six consecutive patients with osteoarthritis and a slight-to-moderate varus deformity undergoing raTKA were prospectively included in this study. Prior to surgery and at follow-up, a full leg radiograph (FLR) under weight-bearing conditions was performed. In addition, a computed tomography (CT) scan was conducted for preoperative planning. The hip-knee-ankle angle (HKA), mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibial angle (mMPTA) and joint line convergence angle (JLCA) were measured in the preoperative and follow-up FLR as well as in the CT scout (without weight-bearing) by three independent raters. Furthermore, the HKA was intraoperatively assessed with the MAKO™ system before and after raTKA. RESULTS: Significantly higher HKA values were identified for intraoperative deformity assessment using the MAKO system compared to the preoperative FLR and CT scouts (p = 0.006; p = 0.05). Intraoperative assessment of the HKA with final implants showed a mean residual varus deformity of 3.2° ± 1.9°, whereas a significantly lower residual varus deformity of 1.4° ± 1.9° was identified in the postoperative FLR (p < 0.001). The mMPTA was significantly higher in the preoperative FLR than in the CT scouts (p < 0.001). Intraoperatively, the mMPTA was adjusted to a mean of 87.5° ± 0.9° with final implants, while significantly higher values were measured in postoperative FLRs (p < 0.001). Concerning the mLDFA, no significant differences could be identified. CONCLUSION: The clinical importance of this study lies in the finding that there is a difference between residual varus deformity measured intraoperatively with the MAKO™ system and those measured in postoperative FLRs. This has implications for preoperative planning as well as intraoperative fine-tuning of the implant position during raTKA to avoid overcorrection of knees with slight-to-moderate varus osteoarthritis. LEVEL OF EVIDENCE: Level IV.

Validation of a Robotic Testbench for Evaluating Biomechanical Effects of Implant Rotation in Total Knee Arthroplasty on a Cadaveric Specimen.

In this study, we developed and validated a robotic testbench to investigate the biomechanical compatibility of three total knee arthroplasty (TKA) configurations under different loading conditions, including varus-valgus and internal-external loading across defined flexion angles. The testbench captured force-torque data, position, and quaternion information of the knee joint. A cadaver study was conducted, encompassing a native knee joint assessment and successive TKA testing, featuring femoral component rotations at -5°, 0°, and +5° relative to the transepicondylar axis of the femur. The native knee showed enhanced stability in varus-valgus loading, with the +5° external rotation TKA displaying the smallest deviation, indicating biomechanical compatibility. The robotic testbench consistently demonstrated high precision across all loading conditions. The findings demonstrated that the TKA configuration with a +5° external rotation displayed the minimal mean deviation under internal-external loading, indicating superior joint stability. These results contribute meaningful understanding regarding the influence of different TKA configurations on knee joint biomechanics, potentially influencing surgical planning and implant positioning. We are making the collected dataset available for further biomechanical model development and plan to explore the 6 Degrees of Freedom (DOF) robotic platform for additional biomechanical analysis. This study highlights the versatility and usefulness of the robotic testbench as an instrumental tool for expanding our understanding of knee joint biomechanics.

Development of an Exoskeleton Platform of the Finger for Objective Patient Monitoring in Rehabilitation.

This paper presents the application of an adaptive exoskeleton for finger rehabilitation. The system consists of a force-controlled exoskeleton of the finger and wireless coupling to a mobile application for the rehabilitation of complex regional pain syndrome (CRPS) patients. The exoskeleton has sensors for motion detection and force control as well as a wireless communication module. The proposed mobile application allows to interactively control the exoskeleton, store collected patient-specific data, and motivate the patient for therapy by means of gamification. The exoskeleton was applied to three CRPS patients over a period of six weeks. We present the design of the exoskeleton, the mobile application with its game content, and the results of the performed preliminary patient study. The exoskeleton system showed good applicability; recorded data can be used for objective therapy evaluation.

Reamed intramedullary exchange nailing in the operative treatment of aseptic tibial shaft nonunion.

PURPOSE: The aim of this study was to evaluate a standardized treatment protocol regarding the rate of secondary bone union, complications, and functional outcome. METHODS: This study was started as a prospective study in a single Level I Trauma Centre between 2003 and 2012. The study group consisted of 188 patients with the diagnosis of an aseptic tibial shaft nonunion. Exchange nailing was performed following a standardized surgical protocol. Long-term follow-up was analyzed for rate of bone healing and functional outcome. RESULTS: Osseous healing was achieved in 182 out of 188 patients (97 %). In 165 out of 188 patients (88 %), bone healing was observed timely and uneventfully after a single exchange nailing procedure. An open approach was necessary in 32 patients (17 %). Twenty-three patients (12 %) required additional therapy such as extracorporeal shock wave therapy. Post-operative complications were observed in seven patients (4 %). Almost all patients demonstrated osseous healing within 12 months, with the majority of osseous healing occurring within six months. A relevant shortening of the fractured tibia was observed in 20 out of 188 patients (11 %). After a median follow-up of 23 months (range 12-45 months), outcome was evaluated using the assessment system of Friedman/Wyman. In summary, 154 out of 188 patients (82 %) had a good functional long-term result. DISCUSSION: Reamed intramedullary exchange nailing including correction of axis alignment is a safe and effective treatment of aseptic tibial shaft nonunion with a high rate of bone healing and a good radiological and functional long-term outcome.

The Vega advanced third generation posterior stabilized total knee arthroplasty system enables the restoration of range of motion for high demanding daily activities - A 5-years follow-up study.

BACKGROUND: The Vega System® PS (Aesculap AG, Tuttlingen, Germany) is an advanced, third generation fixed implant that aims to mimic natural knee kinematics by optimizing pivotal motion while reducing surface stress. This study evaluated mid-term survival and clinical outcomes, including range of motion (ROM) of the modern posterior stabilized implant in order to analyse whether this biomechanically successful implant reaches good results in situ. METHODS: The first 100 patients to receive the Vega PS System for total knee arthroplasty were invited to take part in this single centre, single surgeon study. Of these, 84 patients were clinically assessed 5-6 years postoperatively. Data which was obtained during this follow-up examination included revision data, range of motion and clinical scores. RESULTS: The 5-year survival rate for exchange of any component was 97.6%, whereby two patients required replacement of the polyethylene gliding surface. Secondary patella resurfacing was performed in 7 patients. Significantly improved results in comparison to the preoperative state could be obtained at the follow-up: KOOS improved from 39.4 to 78.8, SF-12 PCS improved from 32.1 to 42 SF-12 MCS improved from 46 to 53.8 and patella pain improved from 2.7 to 0.3. The mean ROM of the 84 patients after 5 years was 133.1° and mean total KSS was 189.9. DISCUSSION & CONCLUSIONS: This study demonstrates a high survival rate of the Vega PS System® and significant improvements in clinical outcomes 5 years after implantation. The obtained mean ROM indicates that this implant provides good flexibility of the knee joint, allowing a high number of activities. However, due to the rate of secondary patella implantation, routine resurfacing of the patella for all PS TKA cases is highly recommended. CLINICAL TRIALS REGISTRATION: The study was registered at clinicaltrials.gov (NCT02802085).

Risk of Interprosthetic Femur Fracture Is Associated with Implant Spacing-A Biomechanical Study.

BACKGROUND: Ipsilateral revision surgeries of total hip or knee arthroplasties due to periprosthetic fractures or implant loosening are becoming more frequent in aging populations. Implants in revision arthroplasty usually require long anchoring stems. Depending on the residual distance between two adjacent knee and hip implants, we assume that the risk of interprosthetic fractures increases with a reduction in the interprosthetic distance. The aim of the current study was to investigate the maximum strain within the femoral shaft between two ipsilateral implants tips. METHODS: A simplified physical model consisting of synthetic bone tubes and metallic implant cylinders was constructed and the surface strains were measured using digital image correlation. The strain distribution on the femoral shaft was analyzed in 3-point- and 4-point-bending scenarios. The physical model was transferred to a finite element model to parametrically investigate the effects of the interprosthetic distance and the cortical thickness on maximum strain. Strain patterns for all parametric combinations were compared to the reference strain pattern of the bone without implants. RESULTS: The presence of an implant reduced principal strain values but resulted in distinct strain peaks at the locations of the implant tips. A reduced interprosthetic distance and thinner cortices resulted in strain peaks of up to 180% compared to the reference. At low cortical thicknesses, the strain peaks increased exponentially with a decrease in the interprosthetic distance. An increasing cortical thickness reduced the peak strains at the implant tips. CONCLUSIONS: A minimum interprosthetic distance of 10 mm seems to be crucial to avoid the accumulation of strain peaks caused by ipsilateral implant tips. Interprosthetic fracture management is more important in patients with reduced bone quality.

Survival of Patient-Specific Unicondylar Knee Replacement.

Unicompartmental knee arthroplasty (UKA) in isolated medial or lateral osteoarthritis leads to good clinical results. However, revision rates are higher in comparison to total knee arthroplasty (TKA). One reason is suboptimal fitting of conventional off-the-shelf prostheses, and major overhang of the tibial component over the bone has been reported in up to 20% of cases. In this retrospective study, a total of 537 patient-specific UKAs (507 medial prostheses and 30 lateral prostheses) that had been implanted in 3 centers over a period of 10 years were analyzed for survival, with a minimal follow-up of 1 year (range 12 to 129 months). Furthermore, fitting of the UKAs was analyzed on postoperative X-rays, and tibial overhang was quantified. A total of 512 prostheses were available for follow-up (95.3%). Overall survival rate (medial and lateral) of the prostheses after 5 years was 96%. The 30 lateral UKAs showed a survival rate of 100% at 5 years. The tibial overhang of the prosthesis was smaller than 1 mm in 99% of cases. In comparison to the reported results in the literature, our data suggest that the patient-specific implant design used in this study is associated with an excellent midterm survival rate, particularly in the lateral knee compartment, and confirms excellent fitting.

Biomechanical Properties of Repair Cartilage Tissue Are Superior Following Microdrilling Compared to Microfracturing in Critical Size Cartilage Defects.

BACKGROUND/AIM: Common surgical treatment options for large focal chondral defects (FCDs) in the knee include microfracturing (MFX) and microdrilling (DRL). Despite numerous studies addressing MFX and DRL of FDCs, no in vivo study has focused on biomechanical analysis of repair cartilage tissue in critical size FCDs with different amounts of holes and penetration depths. MATERIALS AND METHODS: Two round FCDs (d=6 mm) were created on the medial femoral condyle in 33 adult merino sheep. All 66 defects were randomly assigned to 1 control or 4 different study groups: 1) MFX1, 3 holes, 2 mm depth; 2) MFX2, 3 holes, 4 mm depth; 3) DRL1, 3 holes, 4 mm depth; and 4) DRL2, 6 holes, 4 mm depth. Animals were followed up for 1 year. Following euthanasia, quantitative optical analysis of defect filling was performed. Biomechanical properties were analysed with microindentation and calculation of the elastic modulus. RESULTS: Quantitative assessment of defect filling showed significantly better results in all treatment groups compared to untreated FCDs in the control group (p<0.001), with the best results for DRL2 (84.2% filling). The elastic modulus of repair cartilage tissue in the DRL1 and DRL2 groups was comparable to the adjacent native hyaline cartilage, while significantly inferior results were identified in both MFX groups (MFX1: p=0.002; MFX2: p<0.001). CONCLUSION: More defect filling and better biomechanical properties of the repair cartilage tissue were identified for DRL compared to MFX, with the best results for 6 holes and 4 mm of penetration depth. These findings are in contrast to the current clinical practice with MFX as the gold standard and suggest a clinical return to DRL.

[Techniques and results of primary hip arthroplasty in geriatric acetabular fractures]. / Techniken und Ergebnisse der primären Totalendoprothese bei geriatrischer Acetabulumfraktur.

As a result of demographic changes, there is an increase in geriatric acetabular fractures [1, 2]. Geriatric patients often have comorbidities, such as pre-existing coxarthritis, reduced bone quality or limited compliance, which makes injury-adapted follow-up treatment difficult [3]. As a result joint-preserving interventions often fail at an early stage, so that hip arthroplasty is necessary in the short term. The 1­year mortality after surgically stabilized acetabular fractures is 8.1%, a significant increase by a factor of 4 compared to the age group [4]. This illustrates that differentiated criteria for the indication of joint-preserving surgery versus arthroplasty are necessary to avoid reoperations and complications. Criteria for the indications for primary arthroplasty are fracture type, pre-existing coxarthritis, poor bone quality, limited compliance and patient age (> 75 years) [5, 6].In the following article, three treatment strategies for geriatric acetabular fractures and periprosthetic acetabular fractures are presented; the 1­stage prosthesis implantation without osteosynthesis, the 1­stage prosthesis implantation with osteosynthesis and the 2­stage approach with limited osteosynthesis and early total arthroplasty. The advantages and disadvantages of these options are presented based on cases and the various aspects of the treatment. The treatment of geriatric acetabular fractures is an operative challenge for the surgeon and requires a high level of expertise in both special trauma surgery and revision arthroplasty and thus represents a special interface in the fields of orthopedics and trauma surgery.

Pulsatile Lavage During Cementation of Total Knee Arthroplasty - Is Fixation Impaired? A Cadaver Study.

BACKGROUND/AIM: Increasing economic pressure in modern healthcare necessitates an increase in efficiency in total knee arthroplasty (TKA) while maintaining high-quality outcomes. Removal of debris using pulsatile lavage (PL) during cement polymerization may considerably reduce the operative duration. However, water can penetrate the interface, resulting in impaired implant fixation. The aim of the present study was to investigate the impact of early-onset PL during bone cement polymerization on implant fixation and operative duration. MATERIALS AND METHODS: Cemented implantation of tibial trays was performed in 20 fresh-frozen human tibiae from 10 donors in a matched-pair study design in two groups: 1) PL during cement polymerization; and 2) PL after completion of the polymerization process. The cement penetration depth was analysed by computed tomography (CT), and the pull-out force was measured to evaluate primary implant fixation. The duration of the procedure was recorded for both groups. RESULTS: Comparable pull-out forces were observed in the experimental (2,213 N) and control groups (2,350 N; p=0.68). The mean depth of cement penetration was similar in both groups. PL during cement polymerization could decrease the operative duration by 10 min. CONCLUSION: The application of PL during cement polymerization could significantly reduce operative duration and had no adverse effect on the mechanical fixation of the tibial component.

Biomechanical comparison of acetabular fracture fixation with stand-alone THA or in combination with plating.

PURPOSE: A common surgical treatment in anterior column acetabular fractures with preexisting osteoarthritis is THA, which is commonly combined with plate osteosynthesis. Implantation of a solitary revision cup cranially fixed to the os ilium is less common. The purpose of this study was to compare the stabilization of anterior column acetabular fractures fixed with a cranial socket revision cup with flange and iliac peg or with a suprapectineal plate osteosynthesis combined with an additional revision cup. METHODS: In 20 human hemipelves, an anterior column fracture was stabilized by either a cranial socket revision cup with integrated flange (CF = Cup with Flange) or by a suprapectineal plate combined with a revision cup (CP = Cup and Plate). Each specimen was loaded under a stepwise increasing dynamic load protocol. Initial construct stiffness, interfragmentary movements along the fracture line, as well as femoral head movement in relation to the acetabulum were analyzed. RESULTS: Both groups showed comparable initial construct stiffness (CP: 3180 ± 1162 N/mm and CF: 3754 ± 668 N/mm; p = 0.158). At an applied load of 1400 N, interfragmentary movements at the acetabular (p = 0.139) and the supraacetabular region (p = 0.051) revealed comparable displacement for both groups and remained below 1 mm. Femoral head movement in relation to the acetabulum also remained below 1 mm for both test groups (p = 0.260). CONCLUSION: From a biomechanical point of view, both surgical approaches showed comparable fracture reduction in terms of initial construct stiffness and interfragmentary movement. The potential benefit of the less-invasive cranial socket revision cup has to be further investigated in clinical studies.

[Anterolateral approach to femoral neck fractures in children]. / Anterolateraler Zugang zur Fixation von Schenkelhalsfrakturen im Kindesalter.

OBJECTIVE: Anatomic reduction and stable fixation of pediatric femoral neck fractures. INDICATIONS: All unstable and displaced femoral neck fractures (AO classification 31-E/1.1, 31-E/1.2, 31-M/2.1 I-III, 31-M/3.1 I-III, 31-M/3.2 II-III). CONTRAINDICATIONS: Relative: Stable and nondisplaced femoral neck fractures. SURGICAL TECHNIQUE: The anterolateral approach uses the muscle interval between the gluteus medius and minimus muscles and the tensor fascia lata. It provides access to the anterior part of the hip joint for open reduction and allows the retention and osteosynthesis from the lateral aspect of the femur. By incision of the anterior capsule the blood supply of the femoral head is preserved and the fracture can be visualized. An anatomic reduction should be achieved and a stable osteosynthesis according to the age of child and fracture type and location should be performed. POSTOPERATIVE MANAGEMENT: After stable fixation additional immobilization is not required. Young children are mobilized in a wheel chair with no weight bearing; older children are mobilized with partial weight bearing with crutches. According to the age of the child and fracture type full weight bearing can be allowed after 4-8 weeks after radiographic follow-up. RESULTS: Fractures of the femoral neck in children are rare and often associated with high-energy traumata. Complication rates are high such as avascular necrosis (AVN) of the femoral head, premature epiphyseal closure, nonunion, secondary displacement, coxa vara or infection. Different factors influence the outcome, including initial displacement, fracture classification, timing of reduction, stability of fixation or quality of reduction. However, especially in the lateral fractures the femoral head necrosis can be avoided by protecting the vascular supply. The reader of the article should be enabled to reduce the rate of AVNs by knowledge of the controllable risk factors and no longer accept AVN as predestined. There is a controversial discussion on the benefit of hematoma evacuation of the hip joint capsule and its influence on the rate of femoral head necrosis.

An Adaptive Mechatronic Exoskeleton for Force-Controlled Finger Rehabilitation.

This paper presents a novel mechatronic exoskeleton architecture for finger rehabilitation. The system consists of an underactuated kinematic structure that enables the exoskeleton to act as an adaptive finger stimulator. The exoskeleton has sensors for motion detection and control. The proposed architecture offers three main advantages. First, the exoskeleton enables accurate quantification of subject-specific finger dynamics. The configuration of the exoskeleton can be fully reconstructed using measurements from three angular position sensors placed on the kinematic structure. In addition, the actuation force acting on the exoskeleton is recorded. Thus, the range of motion (ROM) and the force and torque trajectories of each finger joint can be determined. Second, the adaptive kinematic structure allows the patient to perform various functional tasks. The force control of the exoskeleton acts like a safeguard and limits the maximum possible joint torques during finger movement. Last, the system is compact, lightweight and does not require extensive peripherals. Due to its safety features, it is easy to use in the home. Applicability was tested in three healthy subjects.

Reamed intramedullary exchange nailing: treatment of choice of aseptic femoral shaft nonunion.

BACKGROUND: The aim of this study was to evaluate a standardized method of treatment of femoral nonunion of the isthmal femur excluding non-united metaphyseal fractures. METHODS: Between 2003 and 2010, 72 consecutive patients with nonunion of the femoral shaft were operated using a standardized protocol in our trauma department and followed up for successful union and functional result. RESULTS: Osseous healing was observed in 71 patients (98%). Only one patient was lacking bone healing following a time period of 24 months after the first exchange nailing and 5 months after the second exchange nailing. In 59 patients (82%), uneventful and timely bone healing after exchange nailing was detected. In 18% of patients (n = 13), delayed bone healing was observed and required additional therapy. In the majority of patients (61%), bone healing occurred within the first 2 to 5 months, only 18% of patients' duration of bone healing exceeded 8 months. In 62 patients (86%), no relevant or clinically apparent leg-length discrepancy prior to and after exchange nailing was detected as well as no significant axis deviation or malrotation. Functional studies including simple clinical gait and standing analysis, return to activities of daily life, return to sports activities, and return to work were all reached on a satisfying level. DISCUSSION: Reamed intramedullary exchange nailing as described in this study is the treatment of choice for aseptic femoral shaft nonunion with a high rate of bone healing and a low rate of complications including length discrepancy or malrotation and a good functional outcome.