Heidari et al 2020b - Revision history

Rimni at 13:24, 20 May 2021

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Milad at 21:06, 12 November 2020

2020-11-12T21:06:40Z

Milad at 14:01, 2 November 2020

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Rimni at 10:52, 23 October 2020

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Rimni at 10:43, 23 October 2020

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Rimni at 14:19, 22 October 2020

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Rimni at 13:38, 22 October 2020

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Rimni at 12:47, 22 October 2020

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Rimni at 12:47, 22 October 2020

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Rimni at 12:46, 22 October 2020

2020-10-22T12:46:19Z

@@ Line 61: / Line 61: @@
 |style="padding:10px;"|  [[Image:Review_645432982081-image5.jpeg|600px]]
 |- style="text-align: center; font-size: 75%;"
-| colspan="1" style="padding-bottom:10px;"| '''Figure2'''. (a) Coonrad Morrey elbow implant. (b) Modeled the humeral component of the Coonrad-Morrey implant
+| colspan="1" style="padding-bottom:10px;"| '''Figure 2'''. (a) Coonrad Morrey elbow implant. (b) Modeled the humeral component of the Coonrad-Morrey implant
 |}

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 |style="padding:10px;"|  [[Image:Review_645432982081-image5.jpeg|600px]]
 |- style="text-align: center; font-size: 75%;"
-| colspan="1" style="padding-bottom:10px;"| '''Figure 2'''. (a) Coonrad Morrey elbow implant. (b) Modeled the humeral component of the Coonrad-Morrey implant
+| colspan="1" style="padding-bottom:10px;"| '''Figure2'''. (a) Coonrad Morrey elbow implant. (b) Modeled the humeral component of the Coonrad-Morrey implant
 |}

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 ===2.1 Modeling elbow implant===
-Coonrad-Morrey (Zimmer, Warsaw, IN) is one of the most commonly used linked elbow implants. Therefore, this implant was modeled in this study. A caliper is used to obtain the dimensions. The axis of the humeral component is perpendicular to the long axis of the stem [4,7]. The humeral component was modeled, using Solidworks (Dassault Systèmes, USA) software ([[#img-2|Figure 12]]).
+Coonrad-Morrey (Zimmer, Warsaw, IN) is one of the most commonly used linked elbow implants. Therefore, this implant was modeled in this study. A caliper is used to obtain the dimensions. The axis of the humeral component is perpendicular to the long axis of the stem [4,7]. The humeral component was modeled, using Solidworks (Dassault Systèmes, USA) software ([[#img-2|Figure 2]]).
 <div id='img-1'></div>
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 | colspan="1" style="padding-bottom:10px;"| '''Figure 2'''. (a) Coonrad Morrey elbow implant. (b) Modeled the humeral component of the Coonrad-Morrey implant
 |}
 ===2.2  Construction of elbow bone===

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 [48] Van S.D., Naert I., Andersson M., Brajnovic I., Van C.J., Suetens P. A custom template and definitive prosthesis allowing immediate implant oading in the maxilla: a clinical report. Int. J. Oral Maxillofac Implants., 17:663-670, 2002.
-[49] Vrielinck L, Politis C, Schepers S, Pauwels M, Naert I. Image-based planning and clinical validation of zygoma and pterygoid implant placement in patients with severe bone atrophy using customized drill guides. Preliminary results from a prospective clinical follow-up study. Int. J. Oral Maxillofac Surg.,( 32):7-14, 2003.
+[49] Vrielinck L., Politis C., Schepers S., Pauwels M., Naert I. Image-based planning and clinical validation of zygoma and pterygoid implant placement in patients with severe bone atrophy using customized drill guides. Preliminary results from a prospective clinical follow-up study. Int. J. Oral Maxillofac Surg., 32(1):7-14, 2003.
-[50] Gschwend N. Present State of art in elbow arthroplasty. Acta Orthopædica Belgica, 68(2):100-117, 2002.
+[50] Gschwend N. Present state of art in elbow arthroplasty. Acta Orthopædica Belgica, 68(2):100-117, 2002.
-[51] Stacpoole RA, Ferreira LM, King GJW, Johnson JA. Development of Computer-Assisted Radial Head Replacement Rebecca, International Conference on Medical Image Computing and Computer-Assisted Intervention. Medical Image Computing and Computer-Assisted Intervention, 199-206, 2003.
+[51] Stacpoole R.A., Ferreira L.M., King G.J.W., Johnson J.A. Development of computer-assisted radial head replacement. International Conference on Medical Image Computing and Computer-Assisted Intervention, MICCAI 2003: Medical Image Computing and Computer-Assisted Intervention, 199-206, 2003.
-[52]  K. A. Hildebrand, S. D. Patterson, W. D. Regan, J. C. MacDermid and G. J. King, “Functional outcome of semiconstrained total elbow arthroplasty,” J. Bone Joint Surg. Am. Vol. 82, pp. 1379-1386, 2000.
+[52]   Hildebrand K.A.,  Patterson S.D.,  Regan W.D.,  MacDermid J.C.,  King G.J. Functional outcome of semiconstrained total elbow arthroplasty. J. Bone Joint Surg. Am., 82:379-1386, 2000.
-[53] Kamineni S, Morrey BF. Proximal ulnar reconstruction with strut allograft in revision total elbow arthroplasty. J. Bone Joint Surg. Am, 86:1223-1229, 2004.
+[53] Kamineni S., Morrey B.F. Proximal ulnar reconstruction with strut allograft in revision total elbow arthroplasty. J. Bone Joint Surg. Am., 86:1223-1229, 2004.
-[54] King GJ, Itoi E, Niebur GL, Morrey BF, An KN. Motion and laxity of the capitellocondylar total elbow prosthesis. J. Bone Joint Surg. Am.,76(7):1000-1008, 1994.
+[54] King G.J., Itoi E., Niebur G.L., Morrey B.F., An K.N. Motion and laxity of the capitellocondylar total elbow prosthesis. J. Bone Joint Surg. Am., 76(7):1000-1008, 1994.
 </div>

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 |style="padding:10px;"|  [[Image:Review_645432982081-image13.jpeg|390px]]
 |- style="text-align: center; font-size: 75%;"
-| colspan="1" style="padding:10px;"| '''Figure 4'''. (a) The anatomic flexion-extension axis of distal humerus. (b) Flexion-extension axis (c) transparent view of the implanted bones
+| colspan="1" style="padding:10px;"| '''Figure 4'''. (a) The anatomic flexion-extension axis of distal humerus. (b) Flexion-extension axis. (c) transparent view of the implanted bones
 |}

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-{| style="text-align: center; border: 1px solid #BBB; margin: 1em auto; width: auto;max-width: auto;"
+{| style="text-align: center; border: 1px solid #BBB; margin: 1em auto; width: 70%;"
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 |style="padding:10px;"|  [[Image:Review_645432982081-image17.jpeg|432px]]

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-{| style="text-align: center; border: 1px solid #BBB; margin: 1em auto; width: 65%;"
+{| style="text-align: center; border: 1px solid #BBB; margin: 1em auto; width: 70%;"
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 ==4. Discussion==
-There are no good results for the elbow joint replacements when compared with the knee and hip replacements. Early loosening of joint arthroplasties, instability, limited range of motion, and dislocation in patients with articulated fixators, subluxation, and excessive polyethylene wear are the results of incorrect selection of the flexion-extension axis during surgery [1, 2, 31]. While various mechanisms of implant loosening, as the main causes of elbow implant failure, have been recommended, implant malpositioning might probably be the important underlying reason. This axis is related to the alignment tools during surgery. After surgery, the kinematics of the elbow axis is altered; hence, the muscle moment arms and the arm motion pattern also change. This enhances the load at the articular bearing, which causes loosening and implant wear [32, 33]. Proper selection of the flexion-extension axis results in accurate implant placement. A very tiny error on the distal humerus width (only a few millimeters in the axis endpoints selection) can change several degrees in orientation. Previous studies had investigated the importance of implant alignment with respect to load transfer and kinematics [34, 35]. The position of the stem in the canal has a vital role in the survivability of the implant. Optimum implant positioning and technique used for its alignment are vital parameters to improve clinical results. A study showed that a gradual increase in prosthetic survival is possible through the development of surgical techniques [36]. The orthopedic CAD/CAM surgery is becoming more popular with a concentration on the spine, hip, and knee. However, the elbow joint suffers from a lack of knowledge [37, 38]. Hence, in this study, a technique was used to model the surgical guide template to identify the flexion-extension axis, position, and orientation of stem inside the humerus canal. The used technique permitted the conversion of a radiographic guide to a surgical guide template.
+There are no good results for the elbow joint replacements when compared with the knee and hip replacements. Early loosening of joint arthroplasties, instability, limited range of motion, and dislocation in patients with articulated fixators, subluxation, and excessive polyethylene wear are the results of incorrect selection of the flexion-extension axis during surgery [1,2,31]. While various mechanisms of implant loosening, as the main causes of elbow implant failure, have been recommended, implant malpositioning might probably be the important underlying reason. This axis is related to the alignment tools during surgery. After surgery, the kinematics of the elbow axis is altered; hence, the muscle moment arms and the arm motion pattern also change. This enhances the load at the articular bearing, which causes loosening and implant wear [32,33]. Proper selection of the flexion-extension axis results in accurate implant placement. A very tiny error on the distal humerus width (only a few millimeters in the axis endpoints selection) can change several degrees in orientation. Previous studies had investigated the importance of implant alignment with respect to load transfer and kinematics [34,35]. The position of the stem in the canal has a vital role in the survivability of the implant. Optimum implant positioning and technique used for its alignment are vital parameters to improve clinical results. A study showed that a gradual increase in prosthetic survival is possible through the development of surgical techniques [36]. The orthopedic CAD/CAM surgery is becoming more popular with a concentration on the spine, hip, and knee. However, the elbow joint suffers from a lack of knowledge [37,38]. Hence, in this study, a technique was used to model the surgical guide template to identify the flexion-extension axis, position, and orientation of stem inside the humerus canal. The used technique permitted the conversion of a radiographic guide to a surgical guide template.
-Visual cues and jigs are the current surgical techniques used to estimate the elbow’s flexion-extension axis for TEA [9, 16, 17]. The surgeons extend this line (during surgery) visually to make an intersection between the lateral and medial surfaces of the distal humerus, close to the epicondyles. Morrey et al. (2000) presented this technique in an external dynamic joint distractor [11]. However, Brownhill et al. (2006) proved that this technique can lead to prominent errors for the flexion-extension axis. Nevertheless, the use of cues and jigs may lead to flexion-extension axis identification errors upwards of 10° [19, 39].
+Visual cues and jigs are the current surgical techniques used to estimate the elbow’s flexion-extension axis for TEA [9,16,17]. The surgeons extend this line (during surgery) visually to make an intersection between the lateral and medial surfaces of the distal humerus, close to the epicondyles. Morrey et al. (2000) presented this technique in an external dynamic joint distractor [11]. However, Brownhill et al. (2006) proved that this technique can lead to prominent errors for the flexion-extension axis. Nevertheless, the use of cues and jigs may lead to flexion-extension axis identification errors upwards of 10° [19,39].
-Recently, CAD/CAM has been employed to enhance the precision of determining the elbow’s flexion-extension axis. The appropriate implant position and mechanical limb alignment could be more accurately produced with the computer-assisted system compared with the conventional and traditional techniques. The establishment of a preoperative plan, as well as diagnosis, could be more reliable when the 3D medical image of the anatomy was obtained. Surgeons are allowed to use navigated guidance by registering the preoperative data to the patient while referencing the benchmarks on the preoperative plan that is not accessible in the surgical exposure. This can assist the surgeons to create a treatment plan prior to implant placement [40, 41]. The recent progress in medical imaging and computer field aids surgeons to use the newest equipment, such as a CT scanner. The most distinguished benefit of the CT scan method is the higher level of precision than other methods. Its proficiency has been mentioned in previous studies [42]. There are various applications of CAD in biomedical engineering such as tissue engineering, implant design, medical device design, and preoperative simulations.
+Recently, CAD/CAM has been employed to enhance the precision of determining the elbow’s flexion-extension axis. The appropriate implant position and mechanical limb alignment could be more accurately produced with the computer-assisted system compared with the conventional and traditional techniques. The establishment of a preoperative plan, as well as diagnosis, could be more reliable when the 3D medical image of the anatomy was obtained. Surgeons are allowed to use navigated guidance by registering the preoperative data to the patient while referencing the benchmarks on the preoperative plan that is not accessible in the surgical exposure. This can assist the surgeons to create a treatment plan prior to implant placement [40,41]. The recent progress in medical imaging and computer field aids surgeons to use the newest equipment, such as a CT scanner. The most distinguished benefit of the CT scan method is the higher level of precision than other methods. Its proficiency has been mentioned in previous studies [42]. There are various applications of CAD in biomedical engineering such as tissue engineering, implant design, medical device design, and preoperative simulations.
 In this study, 3D surgical site reconstruction was achieved, using CT data. This permitted the fabrication of a surgical guide using RP and the virtual implant planning via restorative considerations. The flexion-extension line was expanded to intersect the lateral and medial surfaces of the distal humerus, using Materialise Mimics software package. The usual method was used to match the planned and achieved positions by measuring the transfer precision of the computer-based 3D plan. The results showed that the deviations between the achieved and planned holes at the bone apex were 0.28 mm, 0.59 mm, 0.57 mm, and 0.58 mm for samples 1, 2, 3, and 4 respectively in the posterior/anterior direction. However, the deviations in the medial/lateral direction were 0.25 mm, 0.38 mm, 0.46 mm, and 0.53 mm for Sample 1, 2, 3, and 4, respectively. At the base of the bone, the samples 1, 2, 3, and 4 were experienced deviations at 0.41 mm, 0.26 mm, 0.51 mm, and 0.56 mm respectively in the posterior/anterior direction. Furthermore, the deviations were 0.29 mm, 0.42 mm, 0.58 mm, and 0.32 mm for Sample 1, 2, 3, and 4, respectively, in the medial/lateral direction.
@@ Line 250: / Line 250: @@
 Several studies have investigated the precision of the CAS method. Van Steenberghe et al. (2002) investigated the CAD/CAM surgical guide accuracy in cadavers, whereas Vrielinck et al. (2003) carried out the same study on human subjects [48, 49]. Gschwend et al. (2000) used a template to insert a guiding Steinmann pin inside the humerus bone to make a hole preoperatively [50], while Donald et al. evaluated a different way of humeral stem positioning. The computer-assisted technique for TEA was proven to improve implant alignment compared to the conventional methods [18]. Stacpoole et al. studied the effect of radial head implant position on joint kinematics and tracking using a computer-aided implant placement procedure [51]. Recently, surgeons have attained a modified tool for the alignment of the hip, shoulder, and knee. Although it demonstrated much promise, there has been quite limited application of this technology to the elbow, and has, thus far, been limited to laboratory studies only. Since elbow replacements may not be used by most surgeons, the navigation system may be preferred over higher-volume arthroplasties such as the hip and knee. This may result in a decrease in wear for linked implants and reduced instability for unlinked devices. However, clinical studies should confirm these hypotheses.
-Clinical studies have shown a higher rate of loosening for the humeral component than the ulnar component. Excessive loading of the implant stem is caused by malpositioning of the humeral component [52, 53]. The humeral stem restricts modularity in the orientation and situation of the implant articulation axis. Previous studies showed that the kinematics change of elbow replacement was due to the malrotation of the humeral component. This malposition would cause elbow wear, laxity, and loosening [33, 54]. Consequently, in this study, the surgical guide was designed only for the humeral stem.
+Clinical studies have shown a higher rate of loosening for the humeral component than the ulnar component. Excessive loading of the implant stem is caused by malpositioning of the humeral component [52,53]. The humeral stem restricts modularity in the orientation and situation of the implant articulation axis. Previous studies showed that the kinematics change of elbow replacement was due to the malrotation of the humeral component. This malposition would cause elbow wear, laxity, and loosening [33,54]. Consequently, in this study, the surgical guide was designed only for the humeral stem.
 To the authors’ knowledge, this study is the first to use such a technique for humeral implant positioning. Even though the errors in implant positioning were greater than 1 mm, the results of this study showed improvement in terms of surgical errors. The introduced method possesses a lot of advantages for TEA. Firstly, the surgeon is able to select the size and placement of the hole based on the unique morphology of the humerus bone before surgery. The second advantage is the preoperatively prepared drill guide can be used to make the hole in proper direction and angulation. Thirdly, it does not require complex equipment in the operating room. Last but not least, it is easy to make and use. Furthermore, it is possible to use different drill sizes and it does need to be adjusted by a jig. This study recommends the use of a 3D planned template as a surgical guide as it is a reliable technique for implant placement during surgery.