混合现实在定制翻修髋关节置换术中的应用：第一份病例报告
Summary
使用定制的植入物和混合现实技术进行了复杂的翻修髋关节置换术。据提交人所知，这是文献中描述的关于这种程序的第一次报告。
Abstract
3D打印和解剖结构可视化技术在医学的各个领域正在迅速发展。2019 年 1 月，使用定制的植入物和混合现实进行复杂的翻修髋关节置换术。混合现实的使用可以很好地可视化结构，并导致精确的植入物固定。据作者所知，这是首次描述这两种创新相结合的案例报告。手术资格之前的诊断是左髋臼部分松动。手术期间使用了工程师准备的混合现实耳机和全息图。手术很成功，随后是早期垂直化和患者康复。该团队看到了关节置换术、创伤和骨科肿瘤学的技术发展机会。
Introduction
三维（3D）打印和复杂结构可视化技术在医学的各个领域正在迅速发展。这些包括心血管外科、耳鼻喉科、颌面外科，最重要的是骨科手术1，2，3，4，5。目前，该技术不仅用于骨科手术的直接实现3D打印元件，还用于外科培训，术前计划或术中导航6，7，8。
全髋关节置换术（THA）和全膝关节置换术（TKA）是全球最常进行的骨科外科手术之一。由于患者生活质量的显着改善，THA在之前的出版物中被描述为“世纪手术”9。在波兰，49.937 THA 和 30.615 TKA 在 2019 年进行了10.随着预期寿命的增加，预计髋关节和膝关节置换术的数量呈上升趋势。在改进植入物设计、手术技术和术后护理方面做出了巨大努力。这些进展使患者恢复功能并降低并发症风险的机会更大11，12，13，14。
然而，全球整形外科医生目前面临的巨大挑战是处理非标准患者，这些患者的髋关节解剖学缺陷使得实施现成的植入物变得非常困难甚至不可能15。骨质流失可能是由于严重创伤、伴髋臼突出的进行性退行性骨关节炎、发育性髋关节发育不良、原发性骨癌或转移16，17，18，19，20。植入物选择的问题特别涉及有多次翻修风险的患者，有时还需要非常规治疗。在这种情况下，一个非常有前途的解决方案是为特定患者和骨骼缺陷创建的添加剂制造的3D打印植入物，从而实现非常精确的解剖配合20。
在关节置换术领域，精确的植入物及其可持续固定至关重要。术前和术中 3D 可视化的进展产生了出色的解决方案，如增强现实和混合现实21、22、23、24。术中使用骨和植入物计算机断层扫描 （CT） 全息图可能比传统的放射成像图像更好地放置假体。这项新兴技术可能会增加治疗效果的机会并降低神经血管并发症的风险21，25。
本病例报告涉及一名因无菌松动而接受髋关节翻修手术的患者。为了解决由多次植入失败引起的严重骨质流失，使用了定制的3D打印髋臼植入物。在手术过程中，我们使用混合现实来可视化植入物的位置，以避免损坏有风险的神经血管结构。实现到混合现实头戴显示设备的应用程序允许发出语音和手势命令，从而可以在外科手术过程中在无菌条件下使用它。
一名57岁的女性因初步诊断入院：左髋臼部分松动。患者的病史广泛。在她的一生中，她经历了许多髋关节的外科手术。第一种治疗方法是由于髋关节发育不良引起的骨关节炎引起的髋关节表面置换术（1977-15岁），第二种是由于植入物松动引起的全髋关节置换术（1983-21岁），以及其他两次翻修手术（1998年，2000-37岁和39岁）。而且，患者患有儿童脑瘫引起的痉挛性左侧偏瘫，因左马蹄内翻足畸形反复手术。她还患有胸腰椎骨关节炎、腕管综合征和控制良好的动脉高血压。在进行下一次手术资格之前，最终诊断是左髋臼部分松动引起的疼痛和功能限制增加。患者积极性高，身体活跃，能够应对残疾。
Protocol
该协议遵循华沙医科大学人类研究伦理委员会的指导方针。患者对该程序表示知情同意，并承认将被记录的事实。患者在手术前同意了。 注意：将患者纳入手术项目的基本标准是必须进行干预，因为解剖功能障碍使得无法使用标准植入物。混合现实旨在更好地放置假体，增加手术成功的机会。 1. 准备 准备定制的髋臼植入物，并在患?…
Representative Results
图像预处理盆骨、股骨和内假体的二元掩模由经验丰富的放射技师使用阈值和区域生长算法以及可用软件从 CT DICOM 图像中半自动分割33。准备好的标签图也由放射科医生手动校正。标签图用于增强可视化效果，方法是在下一步中将其添加到CT扫描中。这种方法可以合并体积渲染，从而可以在CT扫描上看到骨骼结构和周围组织，分割部分指示重要组织。分割结果在原…
Discussion
初次和翻修髋关节置换术可能需要个性化，以确保治疗的有效性。然而，与标准程序相比，使用定制植入物需要更长的手术准备时间。定制的3D打印植入物是一种解决方案，它使疾病导致严重骨破坏的非典型患者有机会恢复功能29。由于晚期退行性疾病发展迅速，原发性骨肿瘤或转移引起的骨缺损以及复杂的损伤或多次翻修程序，标准假体不足16.定制的植入物是…
Disclosures
The authors have nothing to disclose.
Acknowledgements
不適用。
这项研究是作为非商业合作的一部分进行的。
Materials
| CarnaLifeHolo v. 1.5.2 | MedApp S.A. | ||
| Custom-Made implant type Triflanged Acetabular Component | BIOMET | REF PM0001779 | |
| Head Constrained Modular Head + 9mm Neck for cone 12/14, Co-Cr-Mo, size 36mm | BIOMET | REF 14-107021 | |
| Polyethylene insert Freedom Ringloc-X Costrained Linear Ringloc-X 58mm for head 36mm / 10 * | BIOMET | REF 11-263658 |
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Cite This Article
Łęgosz, P., Starszak, K., Stanuch, M., Otworowski, M., Pulik, Ł., Złahoda-Huzior, A., Skalski, A. The Use of Mixed Reality in Custom-Made Revision Hip Arthroplasty: A First Case Report. J. Vis. Exp. (186), e63654, doi:10.3791/63654 (2022).