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 Table of Contents  
SHORT COMMUNICATION
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 28

Three-dimensional printing-assisted rotational osteotomy of the femoral neck in the treatment of early osteonecrosis of the femoral head


1 Joint Department, Zhongshan Hospital affilited Guangzhou University of Chinese Medicine, Zhongshan, Guangdong, China
2 Emergency department, Fifth Southern Medical University Hospital, Guangzhou, Guangdong, China

Date of Submission17-Mar-2022
Date of Decision27-Apr-2022
Date of Acceptance29-Apr-2022
Date of Web Publication16-Nov-2022

Correspondence Address:
Dawei Gao
Zhongshan Chinese Medicine Hospital, ZhongShan 528400, Guangdong
China
Liang Chen
Zhongshan Chinese Medicine Hospital, ZhongShan 528400, Guangdong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/digm.digm_8_22

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  Abstract 


Rotational osteotomy of the base of the femoral neck involves osteotomy at the intertrochanteric level and rotation of the femoral head. That is to rotate the avascular collapse of the femoral head to the nonweight-bearing area of the hip joint, thus effectively avoiding further collapse of the femoral head necrosis. Clinical has achieved a certain effect. However, there are also some problems in the operation, such as the individual difference of the neck-shaft angle and the anteversion angle of the femoral neck of the affected hip joint among different patients, the nonunion of the osteotomy end, the mismatch of the relationship between the head and the acetabulum, and the direction and angle of the head rotation. The combined three-dimensional printing technology is expected to ensure the accuracy of osteotomy, to solve the adverse complications, and to improve the surgical efficacy.

Keywords: Application analysis, Early necrosis of the femoral head, Rotational osteotomy of the base of the femoral neck, Three-dimensional printing technology


How to cite this article:
Wan M, He G, Chen L, Gao D, Hu B, Huahui L, Fukai G. Three-dimensional printing-assisted rotational osteotomy of the femoral neck in the treatment of early osteonecrosis of the femoral head. Digit Med 2022;8:28

How to cite this URL:
Wan M, He G, Chen L, Gao D, Hu B, Huahui L, Fukai G. Three-dimensional printing-assisted rotational osteotomy of the femoral neck in the treatment of early osteonecrosis of the femoral head. Digit Med [serial online] 2022 [cited 2022 Nov 29];8:28. Available from: http://www.digitmedicine.com/text.asp?2022/8/1/28/361337




  Introduction Top


Three-dimensional (3D) printing is a rapid prototyping, or cumulative manufacturing technology, that some people call “Digital Revolution”.[1] 3D printing is an emerging technology, whose clinical application is more and more extensive. It has been applied in various fields of orthopedics, especially including the more complicated and high-precision operations. It has obvious advantages in orthopedic surgeries such as spine, pelvis, abdomen, and calcaneus.[2],[3] 3D printing technology can be used in the computer to accurately build specific digital 3D models using existing imaging data.[4] In addition, the 3D digital model can be printed layer by layer by a special 3D printer to form a physical model, which can be used to make a reasonable preoperative planning and assist in the operation.[5] It is beneficial to the development of surgical precision and individuation. In the early treatment of avascular necrosis of the femoral head, rotational osteotomy of the base of the femoral neck is one of the new methods of hip preservation.[6] Rotational osteotomy of the base of the femoral neck involves osteotomy at the intertrochanteric level and rotation of the femoral head to rotate the avascular collapse of the femoral head to the nonweight-bearing area of the hip joint, to prevent further collapse of the necrotic femoral head.[7] However, there were also individual differences in the neck-shaft angle and anteversion angle of the femoral neck of the affected hip joint among different patients, nonunion of the osteotomy end, mismatch of the relationship between the head and the acetabulum, and the direction and angle of rotation of the head.[8],[9] How to ensure the accuracy of the osteotomy and solve the complications is a big problem in the operation, and the combined 3D printing technology is expected to solve the above problems. The aim of this study was to investigate the feasibility of 3D printing in rotational acetabular osteotomy. The analysis is as follows:

Current status of the treatment of osteonecrosis of the femoral head

Avascular necrosis of the femoral head is one of the important causes of hip dysfunction in orthopedics clinic,[10] and is the common result of various diseases or factors that hinder blood circulation of bone tissue, resulting in the collapse of the femoral head, hip pain, and dysfunction, which seriously affect the daily quality of life of patients.[11] For patients with late femoral head collapse and osteoarthritis of the hip, the pain is severe and the joint function is poor, and joint replacement is the only one. However, for the early femoral head necrosis, Association Research Circulation Osseous Stage( in I, II, and even III stage collapse) is not obvious in young patients. For young patients with early lesions, since their joint is active, artificial acetabulum wear so fast that it may shorten the service life of normal artificial joint. And eventually they may face the risk of artificial joints overhaul. Therefore, a consensus has been reached on the selection of hip preservation surgical methods.[12],[13] Currently, the commonly used hip preservation surgery mainly includes various forms of decompression of the pulp core, rotary osteotomy at the base of the femoral neck, free vascular fibula implantation, porous pole implantation, and rotary osteotomy at the proximal end of the femur.[14],[15],[16] Before the femoral head collapse, the above operation can achieve good clinical efficacy. However, after the femoral head collapse, the operation space for removing dead bone, fully grafting bone, and correction of femoral head collapse is limited, so it is difficult to achieve ideal clinical efficacy. Lieberman et al.[17] in their study found that the failure rate of osteonecrosis of the femoral head patients treated with the above hip saving operation after the femoral head collapse was 39.8%–49%. Therefore, there is still controversy as to which hip preservation surgery is the best therapeutic plan. Currently, there is no hip preservation surgery applicable to all patients with femoral head necrosis, and clinicians should make evaluation and planning based on the reasons, stages, sites, and scope of femoral head necrosis, as well as the advantages and disadvantages of each surgery.[18]

Advantages and difficulties of rotatory osteotomy at the base of the neck

Rotational osteotomy of the base of the femoral neck involves osteotomy at the intertrochanteric level and rotation of the femoral head.[19] That is to rotate the avascular collapse of the femoral head to the nonweight-bearing area of the hip joint, thus effectively avoiding further collapse of the femoral head necrosis. Clinical has achieved a certain effect. On the other hand, intraoperatively, deep within the femoral circumflex artery, the loose solution can be applied more widely to the head of the femoral neck rotation, thus ensuring the femoral head necrosis area as much as possible. By doing so, we can turn out the hip joint weight-bearing area, and improve femoral neck base and the rotational osteotomy in early avascular necrosis of hip treatment, which has obtained the good curative effect[20],[21] the surgery. However, due to different patients with various femoral neck stem angles and the big individual differences among the angles, the complexity of operations, preoperative planning difficulties, bone healing, and postoperative head mortar relationship do affect the surgical curative effect greatly.[22] Besides, its intraoperative subjectivity is larger, so the operation risk is relatively high, and thus such operations are usually performed by high-qualified doctors, who operate based on their personal experiences, two-dimensional (2D) X-ray films, computed tomography (CT) and 3D reconstruction imaged by comprehensive, accurate planning, and intraoperative situations. Therefore, it is dangerous that doctors do not have enough experiences or the exact qualification of orthopedic surgeons through surgical dislocation in the line of the femoral neck base and rotational Osteotomy. And postoperative surgery effect won't be ideal unless the preoperative preparation and intraoperative details are done well enough. Thus, the promotion and application of this operation is limited,[9] which has become an urgent problem for clinical orthopedic surgeons.

Advantage and feasibility analysis of three-dimensional printing in rotational osteotomy of the base of the neck

3D printing is also called “rapid prototyping technology”.[23] On the basis of 3D digital model, the layered manufacturing method could accumulate materials of new technology, and increase material manufacture at present. And 3D printing in orthopedics is mainly used to make plans, manufacture personalized implants and do bone tissue engineering.[24] Using 3D printing to make preoperative plans, design surgical approaches, and simulate intraoperative situationsprocess can effectively improve the quality of surgeries and reduce surgical complications. It has also been applied in hip surgery. Merema et al.[25] showed that the use of 3D printing technology and surgical guidelines is feasible and beneficial for the surgical treatment of acetabular fractures. Chinese scholars such as Xu[26] make use of CT of patients with the pelvic 3D model. They use 3D printing technology to build the 3D physical model, as a secondary to dysplasia of the hip patients with real ShiQuan hip replacement total hip arthroplasty. The use of the model make surgery have a better plan and improve the positioning of the process, so as to simplify the surgery. There is a high degree of consistency between the components planned preoperatively and the actual size used in surgery. As is discussed above, the basic parts of the femoral neck rotation osteotomy, only by means of nuclear (magnetic resonance imaging) or CT technology, can we know well about the patients (from 2D plane), due to the patient's individual differences. Those technologies can provide surgeries with preoperative guidance much more effectively. By contrast, not only dose the traditional way of physical model making has complicated manufacturing processes, but also it isn't suitable for the individual differences. With rapid prototyping modeling, 3D play seal can quickly solve those problems. And doctors can apply 3D printing technology in preoperative planning, the choosing of preoperative surgical approach, technique in a big trochanter bone and bone cutting position, ensuring femoral head rotation angle between the rotors and planning of the specifications of the screw. Due to the large differences of individual patients, intraoperative situations are complicated. And traditional auxiliary examination is difficult to help preoperative planning. While vitro models of 3D printing can be internally fixed properly without the need for attempts to develop new plans. In intraoperative operations, we don't need to repeatedly adjust the screw positions or directions. All will be right just with the first perspective screws, and we do not need further adjustments. It also reduces radiation exposure for patients and doctors. At the same time, 3D printing has much advantages such as: individual, accurate preoperative planning, reduce the problems of cutting end bone does not heal and the relationships among the head after a mortar does not match. If performer preoperative preview on the 3D models can be repeated operation process, it will find that there may be problems in the operation and then could adjust operation strategy, so as to make the procedure more refined and more effective. It can reduce the number of intraoperative debugging and shorten the operation time so as to reduce the exposure time of the incision in the air, and reduce the incidence of wound contamination and postoperative complications. Of course, 3D printing also has limitations on 3D model modeling and manufacturing time (especially when these steps may be outsourced and not performed in hospitals), so it is not recommended to use in emergency situations.[27] However, avascular necrosis of the femoral head is not an acute disease, and clinicians have sufficient time for preoperative planning. At the same time, with the continuous development of information technology, 3D printing technology is constantly updated.

To summarize

At present, 3D printing technology is in the stage of vigorous development, and has been applied in many fields such as industry, medical treatment, architecture, education and clothing with its advantages of no need to process complex tools, fast manufacturing speed, and strong simulation.[28],[29] Especially in the medical profession, the secondary treatment, permanent implants and rehabilitation medical equipment in the areas of application have been increasingly mature. Although direct printing tissues and organs technology is still in the initial stage, but the domestic and foreign researchers have make full use of 3D printing technology in the application of auxiliary treatment. In this way, The doctor can optimize the preoperative planning, facilitate diagnosis and preoperative training. It is helpful for doctor–patient communication, teaching and research, and improving the success rate of surgery. However, 3D printing-assisted rotatory osteotomy at the base of the femoral neck for the treatment of early femoral head necrosis can meet the needs of individual and make the operation more accurate, which has a very broad application prospect in the preoperative planning of this operation, and is expected to benefit patients and make greater contributions to medicine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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