Application and advantages of three dimensional printing technique in anteversion evaluation of  total hip arthroplasty in patients with lumbar degenerative disease

Guowen He; Dawei Gao; Liang Chen

doi:10.4103/digm.digm_6_21

REVIEW ARTICLE

Year : 2021 | Volume : 7 | Issue : 1 | Page : 5

Application and advantages of three dimensional printing technique in anteversion evaluation of total hip arthroplasty in patients with lumbar degenerative disease

Guowen He, Dawei Gao, Liang Chen
Department of Joint, Zhongshan Hospital Affilited Guangzhou University of Chinese Medicine, Zhongshan, China

Date of Submission	22-Apr-2021
Date of Decision	22-Jun-2021
Date of Acceptance	24-Jun-2021
Date of Web Publication	07-Dec-2021

Correspondence Address:
Dawei Gao
Department of Joint, Zhongshan Hospital affilited Guangzhou University of Chinese Medicine, Zhongshan
China
Liang Chen
Department of Joint, Zhongshan Hospital Affilited Guangzhou University of Chinese Medicine, Zhongshan
China

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/digm.digm_6_21

Abstract

In recent years, the application of three-dimensional printing (3DP) in the field of medicine has been expanding and has become the focus of clinical research and application. The 3D reconstruction and 1:1 model can be used to analyze and evaluate the prosthesis installation before operation and improve the accuracy and clinical effect of total hip replacement. In particular, the preoperative evaluation of total hip arthroplasty (THA) in patients with spinal-pelvic sagittal plane deformity is significant. Lumbar degeneration is one of the most common spinal-pelvic sagittal plane malformations, it is difficult to determine acetabular anteversion in THA for these patients, and it is easy to cause postoperative complications. At present, 3DP has been used to determine the anteversion of THA in patients with lumbar degenerative disease, and this article reviews the research and application of 3DP in anteversion evaluation of THA for lumbar degenerative disease, as well as its clinical advantages and challenges.

Keywords: Anteversion, lumbar degeneration, Three-dimensional printing, Total hip replacement

How to cite this article:
He G, Gao D, Chen L. Application and advantages of three dimensional printing technique in anteversion evaluation of total hip arthroplasty in patients with lumbar degenerative disease. Digit Med 2021;7:5

How to cite this URL:
He G, Gao D, Chen L. Application and advantages of three dimensional printing technique in anteversion evaluation of total hip arthroplasty in patients with lumbar degenerative disease. Digit Med [serial online] 2021 [cited 2023 Jun 8];7:5. Available from: http://www.digitmedicine.com/text.asp?2021/7/1/0/331946

Introduction

Total hip arthroplasty (THA) is one of the most common operations in joint surgery; it is the most effective treatment for end-stage hip disease such as osteoarthritis/osteodystrophy, aseptic necrosis of the femoral head, and old femoral neck fracture;^[1] the utility model has the advantages of alleviating pain, correcting joint deformity, and restoring the motion function of the patients' joints as far as possible.^[2] However, complications such as prosthesis dislocation, impingement, and prosthesis loosening may occur after THA.^[3] How to prevent postoperative complications is always a great challenge for joint surgeons. Clinical studies have shown that preoperative evaluation and planning are associated with postoperative complications after THA, whereas patients with spinal-pelvic sagittal plane deformity are complex cases of THA,^[4] there are more postoperative complications in patients with spinal sagittal deformity after artificial joint replacement,^[5] because there is no uniform standard for anteversion angle,^[6] the placement of anteversion angle is closely related to the dislocation, impact, and loosening of the prosthesis, so the preoperative evaluation is very important.^[7] Three-dimensional printing (3DP), as a cutting-edge multidisciplinary technology, has been the focus of research in recent years and has now been widely used in various fields such as medicine, automobile, and architecture,^[8],[9] at present, 3DP technology has been applied to the preoperative evaluation of patients with spinal-pelvic sagittal plane deformity, to evaluate and plan the anteversion of THA with the aid of 3DP in the patients with lumbar degenerative disease,^[10],[11] which is one of the most common diseases of spinal-pelvic sagittal plane deformity, we can get better curative effect.

The Challenge Of Total Hip Arthroplasty For Lumbar Degenerative Disease – Determination Of Anteversion Angle

In THA, the “Acetabular safety zone” with acetabular anteversion angle of 15° ±10° and acetabular abduction angle of 40° ±10°, which was proposed by Lewinnek et al. in 1978,^[12] is now accepted by clinicians, significant increased risk of hip dislocation and prosthesis impact.^[6] However, the “Acetabular safety zone” is based on the conclusion that the anterior plane of the pelvis is parallel to the coronal plane of the body and does not take full account of changes in spinal-pelvic sagittal balance and anterior and posterior pelvic inclination, therefore, conventional “Acetabular safety zone” placement of acetabular components may not be appropriate for patients with spinal-pelvic sagittal imbalance.^[13] Diseases that can cause spinal-pelvic sagittal imbalance include ankylosing spondylitis, lumbar fusion, lumbar degeneration, lumbar compression fractures, and so on, degenerative changes of the lumbar spine are the result of the natural aging of the lumbar spine and the gradual degeneration of its function, it is also one of the more common and complex disorders that cause spinal-pelvic sagittal imbalance,^[14] the complexity of which is reflected in the difficulty in determining the appropriate acetabular anteversion,^[15] according to Esposito et al.^[16] and Blizzard et al.,^[17] patients with lumbar degenerative disease often suffer from lumbar stiffness, limited lumbar mobility, reduced compensatory function, and rely mainly on pelvic compensation to maintain body balance while standing or sitting, prone to anterior dislocation and posterior impingement, and prone to anterior impingement and posterior dislocation due to the reduction of spinal stiffness and compensatory capacity, the pelvis tilts forward and the anteversion angle decreases, in short, the placement of acetabular component anteversion in patients with lumbar degenerative disease can directly affect the curative effect after total hip replacement, and improper placement is prone to postoperative complications, therefore, the primary task of preoperative evaluation of THA in patients with degenerative lumbar spine is to determine the anteversion of the acetabular component. Hence, how do we place the acetabular component anteversion? Is it standing or sitting? There are currently no good standards for anteversion in total hip replacement for patients with lumbar degenerative disease, and the appropriate anteversion must be individually evaluated and planned for each patient before surgery, otherwise, it is easy to cause a series of problems such as artificial joint dislocation, prosthesis impact, and interface wear.

Preoperative Anteversion Assessment Of Total Hip Arthroplasty In Patients With Degenerative Lumbar Spine Using Three-Dimensional Printing

3DP is a method of building up a 3D digital model into a physical model using a variety of sticky materials under the precise control of a computer,^[18] says rapid prototyping, a professor of computer science at the University of California, Berkeley, up to now, there are nearly 20 different technology systems in the field of 3DP at home and abroad according to the different printing materials^[19] before the advent of 3DP, patients with lumbar degenerative disease were often photographed in the preoperative position and the lateral spine-pelvis radiograph in the sitting position, the sagittal balance of the spine and pelvis was roughly evaluated to plan the acetabular cup angle, but the accuracy of this method was not high because the anteversion angle was related to the body position and the lateral X-ray images overlapped easily, it often depends on the clinical experience and skill of individual doctors, and the accuracy of operation cannot be guaranteed. 3DP could fill that gap. 3DP technology path: Through the acquisition of the target imaging data to build the target digital 3D model based on the acquisition data to import the 3D model data into the special 3D printer and print the target layer by layer. There are two methods to evaluate acetabular anteversion by 3DP. One is to collect data of spinal column and pelvis in patients with lumbar degenerative disease, the digital design is used to simulate the operation on the computer, and the acetabular prosthesis is designed according to the lumbar degenerative degeneration and the pelvic condition; three-dimensional spine and pelvis data are constructed using software Mimics, and the proper forward tilt angle can be determined only by specifying the sitting and upright positions, which are used to determine pelvic compensation in patients with degenerative disease, it is recommended based on whether standing or sitting pelvic anteversion is the dominant pelvic anteversion to further estimate the appropriate angle of anteversion. A 1:1 scale 3D model of the lumbar spine and pelvis can be printed, allowing surgeons to evaluate and practice operations directly on the model, which is expensive and time-consuming, but not yet feasible, we will take a closer look. In both cases, 3DP was used to evaluate the anteversion of the acetabular component to better understand the motion and compensation of the lumbar pelvis, it can help doctors to plan the appropriate acetabular anteversion angle before operation, and the accuracy of acetabular anteversion planning can be improved by assisting the design of virtual operation plan before operation, the reduction of intraoperative bleeding time and unnecessary side injury to soft tissue is beneficial to improve the quality of surgery.

Other Applications Of Three-Dimensional Printing In Total Hip Arthroplasty For Lumbar Degenerative Disease

The application of 3DP technology in THA for lumbar degenerative disease only accounts for a small part of preoperative assessment of anteversion. In preoperative assessment, because patients with lumbar degenerative disease are often accompanied by multiple joint degeneration and hyperplasia of the whole body, hip joint is no exception, often accompanied by serious problems such as osteoarthritis/osteodystrophy, acetabular bone hyperplasia, and osteophyte formation,^[20] the 3D printed solid model was reconstructed by 1:1 ratio of acetabular anteroposterior diameter, deep diameter, thickness of posterior wall of acetabulum, femoral deviation,^[21] can be used to measure the size of the acetabular component used in total hip replacement, the depth of the planned osteotomy or the acetabular abrasion, the type of the component, secondly, the simulated operation of total hip replacement can be performed on a 3D digital model to increase the operation proficiency and improve the operation safety. Studies have shown that in the context of assisted surgery, the current studies have shown that the 3DP technique can be used to print the acetabular component guide and that the assisted acetabular component can be placed precisely in the preoperative planning position during surgery, the technique was used in THA in patients with degenerative lumbar spine.^[19] The 3D printed guide plate can be used to guide the placement of the prosthesis according to the preoperative planning, to improve the accuracy and safety of the operation, to effectively reduce the number of adjustments in the operation, shorten the operation time, reduce unnecessary surgical trauma, is conducive to postoperative recovery, but also to reduce the number of intraoperative X-ray fluoroscopy, the amount of radiation given to patients and surgical staff. In the production of surgical materials, 3D printed pads^[22] can be used to fill the bone defect according to different individual acetabular defects and ensure the stability of the hip joint.

Difficulties And Shortcomings Faced

3DP can play an important role in preoperative evaluation and planning of acetabular anteversion in patients with lumbar degenerative disease. It is a new choice for preoperative evaluation of complex THA. However, this innovative technology is also facing some difficulties and shortcomings. First of all, 3DP is expensive because it is not yet widely used in orthopedic medical systems and requires specialized laboratories and technicians, which leads to a large amount of money. Moreover, because 3DP takes a long time to do layer by layer, it is not suitable for some patients who need surgery urgently. Finally, although 3DP is widely used in orthopedic clinic, most of them are limited to printing 3D bone model.^[23] In total hip replacement, it is not possible to evaluate the soft tissue condition by this technique, and good soft tissue release and balance is one of the key factors affecting the functional recovery of the hip joint, it still depends on the clinical experience of the surgeon.

Summary And Outlook

Although the current use of 3DP in total hip replacement in patients with degenerative lumbar spine is still in its infancy, due to the long time and high cost of making a solid model, the primary application at present is the first method described above, which relies on Mimics software Vertion 10.01 (Materi-alise, Japan) to evaluate the spine and pelvis in both sitting and standing positions, but the advantages are clear, the 3DP technique can reconstruct the lumbar spine and pelvis with 3D CT and realize 1:1 reconstruction with 3DP technique. The authors can analyze the degenerative changes of the lumbar spine and the characteristics of the pelvis and make a prejudgment on the development of the cup, especially, the planning of anteversion angle can solve the problem that it is difficult to determine the anteversion angle in the total hip replacement for lumbar degenerative disease, it has a positive effect on improving the technical level of clinical doctors, improving the curative effect of complex operation, reducing the complication of operation, and perfecting the individualized operation of total hip replacement for lumbar degenerative disease.

With the rapid development of imaging and digital medicine, 3DP technology has been widely used in medical field, and the level of orthopedic surgery has been improved. The design of precise, minimally invasive, and intelligent orthopedic surgery has become the trend of development, and the total hip replacement surgery is also developing in the direction of individualization and customization, the application of 3DP technology in total hip replacement has great potential in orthopedic surgery, such as making personalized 3DP artificial joint prosthesis, rationally determining surgical approach according to different individual science, and personalized brace; it is helpful to carry out preoperative planning and preoperative simulation better and to further develop individualized surgical treatment. The application and popularization of 3DP technology are not only new developments in total hip replacement for patients with degenerative lumbar spine, it is the new trend of total hip replacement in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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