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Research Papers

Water Jet Applicator for Interface Tissue Removal in Minimally Invasive Hip Refixation: Testing the Principle and Design of Prototype

[+] Author and Article Information
Gert Kraaij

Department of Orthopaedics,
Leiden University Medical Center,
PO Box 9600,
Leiden 2300RC, The Netherlands;
Department of Biomechanical Engineering,
Delft University of Technology,
Mekelweg 2,
Delft 2628CD, The Netherlands
e-mail: g.kraaij@tudelft.nl

Arjo J. Loeve, Jenny Dankelman

Department of Biomechanical Engineering,
Delft University of Technology,
Mekelweg 2,
Delft 2628CD, The Netherlands

Rob G. H. H. Nelissen, Edward R. Valstar

Department of Orthopaedics,
Leiden University Medical Center,
PO Box 9600,
Leiden 2300RC, The Netherlands;
Department of Biomechanical Engineering,
Delft University of Technology,
Mekelweg 2,
Delft 2628CD, The Netherlands

1Corresponding author.

2Edward R. Valstar passed away in 2017.

Manuscript received November 7, 2018; final manuscript received March 12, 2019; published online April 16, 2019. Assoc. Editor: Rita M. Patterson.

J. Med. Devices 13(2), 021010 (Apr 16, 2019) (11 pages) Paper No: MED-18-1204; doi: 10.1115/1.4043293 History: Received November 07, 2018; Revised March 12, 2019

Mechanical loosening of implants is in the majority accompanied with a periprosthetic interface membrane, which has to be removed during revision surgery. The same is true if a minimal invasive (percutaneous) refixation of a loose implant is done. We describe the requirements for a waterjet applicator for interface tissue removal for this percutaneous hip refixation technique. The technical requirements were either obtained from a literature review, a theoretical analysis, or by experimental setup. Based on the requirements, a waterjet applicator is designed which is basically a flexible tube (outer diameter 3 mm) with two channels. One channel for the water supply (diameter 0.9 mm) and one for suction to evacuate water and morcellated interface tissue from the periprosthetic cavity. The applicator has a rigid tip (length 6 mm), which directs the water flow to create two waterjets (diameter 0.2 mm), both focused into the suction channel. The functionality of this new applicator is demonstrated by testing a prototype of the applicator tip in an in vitro experimental setup. This testing has shown that the designed applicator for interface tissue removal will eliminate the risk of water pressure buildup; the ejected water was immediately evacuated from the periprosthetic cavity. Blocking of the suction opening was prevented because the jets cut through interface tissue that gets in front of the suction channel. Although further development of the water applicator is necessary, the presented design of the applicator is suitable for interface tissue removal in a minimally invasive hip refixation procedure.

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Figures

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Fig. 1

Schematic overview of the waterjet applicator with integrated suction used in initial trials

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Fig. 2

Schematic overview of experimental setup for simulating interface tissue removal

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Fig. 3

A prosthesis surrounded with interface tissue, divided into the four regions A to D

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Fig. 4

Schematic overview of tissue layer thickness measurements: (a) original interface tissue area (white) in a slice, (b) when a circle as large as the instrument diameter fits within the interface tissue area, it is projected on this area, (c) the area of the circle is subtracted from total tissue area, (d) whole interface tissue area is scanned, (e) remaining interface tissue (shown in white) that cannot be reached with the instrument of the diameter shown in “b”

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Fig. 5

Boxplot of removable fraction of interface tissue around 18 loose hip prostheses, accessible for applicator with different diameters, determined per region. Outliers are indicated with a+, the thick horizontal line indicates the 70% threshold of interface tissue to be removed.

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Fig. 6

Design of new waterjet applicator that prevents tissue blocking. The tip is partially represented as a cross section to show the working principle.

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Fig. 7

Bench top prototype applicator tip with two waterjets: (1) 3D rendering, (2) 3D rendering of longitudinal cross section, (3) photograph of separate parts, and (4) photograph of assembled prototype in action. (A) capillary tube, (B) suction channel, (C) body, (D) suction opening, (E) orifices for waterjet, (F) cover, and (G) connection to silicone suction tube. *Prototype slightly bent to get waterjets aimed into suction channel. Dimensions in millimeter.

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Fig. 8

Graphical representation of the simulation used to determine the maximal allowable rigid tip length

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Fig. 9

Example of simulation of instrument with 6 mm rigid tip length: (A) start of instrument insertion, angle = 30 deg, (B) critical point of instrument insertion: rigid tip just fits between prosthesis and cortical bone, angle = 30 deg, (C) successful instrument insertion, angle = 30 deg, and (D) failed instrument insertion due to collision of the rigid tip with the cortical bone, angle = 60 deg

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Fig. 10

Cross section of the applicator with round and elliptical shape of water supply duct. The equations are used to calculate hydraulic diameter Dh and cross-sectional area A of the water duct.

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Fig. 11

At the top, an overview of the experimental setup used in the pilot experiment to determine the optimal number of nozzles and size of the suction opening. At the bottom, the applicator enlarged: (A) hose from high pressure pump, (B) pressure gage measuring waterjet pressure, (C) replaceable blind stop, (D) connector to align suction tube (opening) with the waterjet(s), (E) replaceable tube with different sized suction openings, and (F) suction hose.

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Fig. 12

At the top, a 3D and a sectional view (A-A) of the replaceable blind stop (part C, Fig. 11). Three blind stops were used with, respectively, 1, 2, or 3 holes (Ø0.2 mm each). At the bottom, a 3D and a sectional view (B-B) of the replaceable tube with different suction opening sizes (part E, Fig. 11). Both parts were used in the pilot experiment with waterjet cutting integrated in the suction tube. Dimensions are in millimeter.

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Fig. 13

Experimental setup used for prototype testing

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Fig. 14

Removal rates during waterjet cutting within the contours of a suction tube with different combinations of types of suction openings (varying in size and shape) and number of waterjets

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