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.

Copyright © 2019 by ASME
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Strehle, J. , DelNotaro, C. , Orler, R. , and Isler, B. , 2000, “ The Outcome of Revision Hip Arthroplasty in Patients Older Than Age 80 Years—Complications and Social Outcome of Different Risk Groups,” J. Arthroplasty, 15(6), pp. 690–697. [CrossRef] [PubMed]
Sundfeldt, M. , Carlsson, L. , Johansson, C. , Johansson, C. , Thomsen, P. , Thomsen, P. , and Gretzer, C. , 2006, “ Aseptic Loosening, Not Only a Question of Wear: A Review of Different Theories,” Acta Orthop., 77(2), pp. 177–197. [CrossRef] [PubMed]
Labek, G. , Thaler, M. , Janda, W. , Agreiter, M. , and Stockl, B. , 2011, “ Revision Rates After Total Joint Replacement: Cumulative Results From Worldwide Joint Register Datasets,” J. Bone Jt. Surg., 93, pp. 293–297. [CrossRef]
Kurtz, S. , Ong, K. , Lau, E. , Mowat, F. , and Halpern, M. , 2007, “ Projections of Primary and Revision Hip and Knee Arthroplasty in the United States From 2005 to 2030,” J. Bone Jt. Surg. Am., 89A(4), pp. 780–785.
Badarudeen, S. , Shu, A. C. , Ong, K. L. , Baykal, D. , Lau, E. , and Malkani, A. L. , 2017, “ Complications After Revision Total Hip Arthroplasty in the Medicare Population,” J. Arthroplasty, 32(6), pp. 1954–1958. [CrossRef] [PubMed]
Andreykiv, A. , Janssen, D. , Nelissen, R. , and Valstar, E. R. , 2012, “ On Stabilization of Loosened Hip Stems Via Cement Injection Into Osteolytic Cavities,” Clin. Biomech., 27(8), pp. 807–812. [CrossRef]
Malan, D. F. , Valstar, E. R. , and Nelissen, R. , 2014, “ Percutaneous Bone Cement Refixation of Aseptically Loose Hip Prostheses: The Effect of Interface Tissue Removal on Injected Cement Volumes,” Skeletal Radiol., 43(11), pp. 1537–1542. [CrossRef] [PubMed]
de Poorter, J. J. , Obermann, W. R. , Huizinga, T. W. J. , and Nelissen, R. , 2006, “ Arthrography in Loosened Hip Prostheses. Assessment of Possibilities for Intra-Articular Therapy,” Jt. Bone Spine, 73(6), pp. 684–690. [CrossRef]
de Poorter, J. J. , Hoeben, R. C. , Hogendoorn, S. , Mautner, V. , Ellis, J. , Obermann, W. R. , Huizinga, T. W. J. , and Nelissen, R. , 2008, “ Gene Therapy and Cement Injection for Restabilization of Loosened Hip Prostheses,” Human Gene Ther., 19(1), pp. 83–95. [CrossRef]
de Poorter, J. J. , 2010, “ Gene Therapy and Cement Injection for the Treatment of Hip Prosthesis Loosening in Elderly Patients,” Ph.D. dissertation, Leiden University, Leiden, The Netherlands.
de Poorter, J. J. , Hoeben, R. C. , Obermann, W. R. , Huizinga, T. W. J. , and Nelissen, R. , 2008, “ Gene Therapy for the Treatment of Hip Prosthesis Loosening: Adverse Events in a Phase 1 Clinical Study,” Human Gene Ther., 19(10), pp. 1029–1038. [CrossRef]
Kraaij, G. , Malan, D. F. , van der Heide, H. J. L. , Dankelman, J. , Nelissen, R. G. H. H. , and Valstar, E. R. , 2012, “ Comparison of Ho:YAG Laser and Coblation for Interface Tissue Removal in Minimally Invasive Hip Refixation Procedures,” Medical Eng. Phys., 34, pp. 370–377. [CrossRef]
Kraaij, G. , Tuijthof, G. J. M. , Dankelman, J. , Nelissen, R. G. H. H. , and Valstar, E. R. , 2015, “ Waterjet Cutting of Periprosthetic Interface Tissue in Loosened Hip Prostheses: An In Vitro Feasibility Study,” Med. Eng. Phys., 37, pp. 245–250. [CrossRef] [PubMed]
Schmolke, S. , Pude, F. , Kirsch, L. , Honl, M. , Schwieger, K. , and Kromer, S. , 2004, “ Temperature Measurements During Abrasive Water Jet Osteotomy,” Biomed. Tech., 49(1–2), pp. 18–21. [CrossRef]
Honl, M. , Rentzsch, R. , Muller, G. , Brandt, C. , Bluhm, A. , Hille, E. , Louis, H. , and Morlock, M. , 2000, “ The Use of Water-Jetting Technology in Prostheses Revision Surgery-First Results of Parameter Studies on Bone and Bone Cement,” J. Biomed. Mater. Res., Part B, 53(6), pp. 781–790. [CrossRef]
Hloch, S. , Valicek, J. , and Kozak, D. , 2011, “ Preliminary Results of Experimental Cutting of Porcine Bones by Abrasive Waterjet,” Tech. Gazette, 18, pp. 467–470.
Honl, M. , Rentzsch, R. , Schwieger, K. , Carrero, V. , Dierk, O. , Dries, S. , Louis, H. , Pude, F. , Bishop, N. , Hille, E. , and Morlock, M. , 2003, “ The Water Jet as a New Tool for Endoprosthesis Revision Surgery—An In Vitro Study on Human Bone and Bone Cement,” Bio-Med. Mater. Eng., 13, pp. 317–325.
Schwieger, K. , Carrero, V. , Rentzsch, R. , Becker, A. , Bishop, N. , Hille, E. , Louis, H. , Morlock, M. , and Honl, M. , 2004, “ Abrasive Water Jet Cutting as a New Procedure for Cutting Cancellous Bone–In Vitro Testing in Comparison With the Oscillating Saw,” J. Biomed. Mater. Res., Part B, 71, pp. 223–228.
Breusch, S. J. , and Malchau, H. , 2005, The Well Cemented Total Hip Arthroplasty—Theory and Practice, Springer-Verlag, Berlin, Heidelberg.
Pitto, R. P. , Koessler, M. , and Kuehle, J. W. , 1999, “ Comparison of Fixation of the Femoral Component Without Cement and Fixation With Use of a Bone-Vacuum Cementing Technique for the Prevention of Fat Embolism During Total Hip Arthroplasty—A Prospective, Randomized Clinical Trial,” J. Bone Jt. Surg. Am., 81A, pp. 831–843.
Breusch, S. J. , Norman, T. L. , Schneider, U. , Reitzel, T. , Blaha, J. D. , and Lukoschek, M. , 2000, “ Lavage Technique in Total Hip Arthroplasty—Jet Lavage Produces Better Cement Penetration Than Syringe Lavage in the Proximal Femur,” J. Arthroplasty, 15(7), pp. 921–927. [CrossRef] [PubMed]
Jansson, V. , 1994, “ The Cement-Canal Prosthesis—A New Cementation Technique Studied in Cadaver Femora,” Acta Orthop. Scand., 65(2), pp. 221–224. [CrossRef] [PubMed]
Juliusson, R. , Arve, J. , and Ryd, L. , 1994, “ Cementation Pressure in Arthroplasty—In-Vitro Study of Cement Penetration Into Femoral Heads,” Acta Orthop. Scand., 65(2), pp. 131–134. [CrossRef] [PubMed]
Schmidutz, F. , Dull, T. , Voges, O. , Grupp, T. , Muller, P. , and Jansson, V. , 2012, “ Secondary Cement Injection Technique Reduces Pulmonary Embolism in Total Hip Arthroplasty,” Int. Orthop., 36(8), pp. 1575–1581. [CrossRef] [PubMed]
Cristofolini, L. , Erani, P. , Grupp, T. , Jansson, V. , and Viceconti, M. , 2007, “ In Vitro Long-Term Fatigue Endurance of the Secondary ‘Cement Injection Stem’ Hip Prosthesis,” Artif. Organs, 31(6), pp. 441–451. [CrossRef] [PubMed]
Maleike, D. , Nolden, M. , Meinzer, H. P. , and Wolf, I. , 2009, “ Interactive Segmentation Framework of the Medical Imaging Interaction Toolkit,” Comput. Methods Programs Biomed., 96(1), pp. 72–83. [CrossRef] [PubMed]
Kroh, M. , Hall, R. , Udomsawaengsup, S. , Smith, A. , Yerian, L. , and Chand, B. , 2008, “ Endoscopic Water Jets Used to Ablate Barrett's Esophagus: Preliminary Results of a New Technique,” Surg. Endoscopy Other Interven. Tech., 22(11), pp. 2498–2502. [CrossRef]
White, F. M. , 1998, Fluid Mechanics, McGraw-Hill Higher Education, New York.


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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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