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What is the clinical utility of acoustic and vibrational analyses in uncemented total hip arthroplasty?

Arthroplasty volume 6, Article number: 59 (2024) Cite this article

Abstract

Background

Despite recent developments in THA, a more objective method is needed to assist orthopedic surgeons in identifying the insertion endpoint of the broaching procedure. Therefore, this systematic review evaluated the in-vivo efficacy of various acoustic and vibration analyses in detecting proper implant seating, identifying intraoperative complications, and quantifying the accuracy of predictive modeling using acoustics.

Methods

Four electronic databases were searched on July 23rd, 2023, to retrieve articles evaluating the use of acoustic analysis during THA. The search identified 835 unique articles, which were subsequently screened by two independent reviewers as per our inclusion and exclusion criteria. In total, 12 studies evaluating 580 THAs were found to satisfy our criteria and were included in this review.

Results

Methodologically, analyses have suggested stopping broaching when consecutive blows emit similar acoustic profiles (maximum peak frequency ± 0.5 kHz), which indicates proper implant seating in terms of stability and mitigates subsidence. Also, abrupt large deviations from the typical progression of acoustic signals while broaching are indicative of an intraoperative fracture. Since height, weight, femoral morphological parameters, and implant type have been shown to alter acoustic emissions while hammering, incorporating these factors into models to predict subsidence or intraoperative fracture yielded virtually 100% accuracy in identifying these adverse events.

Conclusion

These findings support that acoustic analyses during THA show promise as an accurate, objective, and non-invasive method to predict and detect proper implant fixation as well as to identify intraoperative fractures.

Trial registration

PROSPERO registration of the study protocol: CRD42023447889, 23 July 2023.

Introduction

Although total hip arthroplasty (THA) often successfully provides long-term relief of pain and improves joint function, concerns remain about periprosthetic or prosthetic fracture, subsidence, stem size mismatch, and instability, all of which may compromise the longevity of the implant [1]. Currently, precise intraoperative implant fixation relies solely on the intuitive judgment of the surgeon. Surgeons need to apply adequate force to achieve firm fixation; however, excessive force can lead to femur fractures, whereas insufficient force results in postoperative subsidence [2, 3] The critical point where the fixation is sufficient and the fracture risk is minimal is the insertion end point [4]. To ensure reaching the end point of insertion, the surgeon depends on experience, audible changes in the sound produced by hammering, and the tactile feel of a well-fitted implant [3, 5] The iatrogenic femur fractures in THAs, which cause protracted operative time, a larger incision, increased blood loss, and delayed postoperative recovery, occurred reportedly in 1% to 28% of THAs [6]. Consequently, a more objective method is needed to measure precise implant fixation and mitigate intraoperative and postoperative complications associated with mal-placement and fractures [7, 8]

Acoustic emission technology and vibrational analyses have shown promise to help surgeons identify the insertion end point, thereby contributing to better implant stability. Various biomechanical models, in-vitro studies, orthopedic models, and cadaveric studies have identified vibration-based methods as a potential non-destructive method to assess the progression of hip fixation in real-time [9,10,11,12]. Additionally, objective and quantitative analysis of hammering sounds during implant insertion has been utilized as a tool for implant fixation and fracture prediction in animal models, human cadavers, in-vitro setups, and in-vivo setups with variable success [1, 5]. Although multiple studies have demonstrated that acoustic analysis could potentially help surgeons identify the end-point during THA, the considerable heterogeneity in study design and outcomes assessed renders it difficult to make comparisons across studies [1]. Therefore, a systematic review of the available literature was indispensable to better understand the potential benefits of acoustic and vibrational analyses in THA, discern trends among studies with similar designs, evaluate methodological quality, inform clinical practices, and guide future research.

Specifically, this review tried to answer the following questions (1) Do vibrational and acoustic analyses accurately detect proper implant seating and subsidence as well as (2) intraoperative fractures for THA? (3) Do patient characteristics or implant type impact acoustic analyses? (4) Are predictive models generated via acoustic analyses for detecting adverse intraoperative and postoperative events accurate?

Methods

Query strategy

A search of Google Scholar, EBSCOhost, MEDLINE, and PubMed was conducted on July 23, 2023, to retrieve articles evaluating the use of acoustic analysis during THA. The “AND” and “OR” Boolean operators were used in conjunction with Medical Subject Headings (Mesh) to build the search term: “Arthroplasty, Replacement, Hip”[Mesh] OR “Arthroplasty, Replacement”[Mesh] OR “Hip Prosthesis”[Mesh] OR total hip arthroplasty OR THA AND “Acoustics”[Mesh] OR “Sound”[Mesh] OR “Vibration”[Mesh] OR “Microscopy, Acoustic”[Mesh] OR acoustic emission OR vibro-acoustic.

Eligibility criteria

Articles were included if they had an English full-text manuscript published, and the study assessed the utility of acoustic or vibrational emission analyses during total hip arthroplasty. Articles were excluded if they were duplicates, published before January 1, 2000, meta-analyses or reviews, editorials, or pre-prints.

Study selection

PROSPERO protocol registration was performed on July 23rd, 2023 (CRD42023447889). This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations [13]. Two assessors, SP and CJH, assessed each study that was returned in our query to determine its eligibility separately. A total of 835 publications were retrieved from the query after duplicates were excluded. After initial screening, 19 were selected for full examination. 12 of these articles satisfied all inclusion criteria. No more articles were found after a thorough review of the reference list of each article. (Fig. 1).

Fig. 1
figure 1

This PRISMA diagram depicts the selection process for article information

Full size image

Study characteristics

Of the 12 studies analyzed, all reported on data from a single institution, with 7 studies being of observational design and 5 cohort studies (Table 1). The sampling frequency of the studies ranged from 44.1 to 64 kHz, with a sampling depth of 16 to 32 bits. A total of 6 studies were about detection of intraoperative fractures, [3, 4, 14,15,16,17] while 10 studies investigated the role of acoustic and vibrational analyses on the detection of implant stability and subsidence [2,3,4, 14,15,16,17,18,19,20]. Additionally, 4 studies evaluated the variability of acoustic profiles emitted per implant and patient characteristics [1, 2, 15, 17]. Five studies examined the accuracy of predictive models generated by acoustic analyses [3, 7, 17, 18, 20].

Table 1 Characteristics of studies included in the final analysis
Full size table

Risk of bias in individual studies

Two separate reviewers, SP and CJH, utilized the Methodological Index for Nonrandomized Studies (MINORS) tool [21] to appraise bias in the included articles. This validated tool rates articles on a 0 to 24 scale in terms of 12 domains related to study design. For each domain, the ratings are as follows: 0 for not reported, 1 for reported but insufficient, and 2 for documented and sufficient. Y.H., an independent third reviewer, resolved any conflicts over the scoring. The average score was 13.8 ± 0.40.

Data extraction and analysis

Data regarding research design, acoustic analysis mode, and parameters, as well as intraoperative and postoperative events, were extracted by S.P. and C.J.H.; The results were then compared for verification and any discrepancies were resolved by consulting a third reviewer, Y.H.; As there was a sizable variation in study design across the included publications that would limit the validity of a meta-analysis, we decided to narratively synthesize their main results.

Ethical approval

All data included in this study were publicly available and did not include protected health information. Therefore, this study was considered exempt from ethical review board approval.

Results

Implant stability detection

Two studies involved the use of vibration analysis and the study of frequency response function (FRF) graphs to identify when implant stability is achieved (Table 2). An increased correlation between the FRFs of the last two hammer blows (r > 0.99) was noticed in those two studies [4, 19]. One of those studies observed that the higher resonance frequencies were more sensitive to changes in implant stability [19]. This could be emphasized by a right shift in the FRF graph, which denotes increased stability and stiffness. Two studies noted that if the maximum peak frequency stabilized (maximum peak frequency ± 0.5 kHz) on consecutive hammer impactions, hammering should be stopped as the implant stability has been attained and further hammering would cause a fracture [15, 16] Additionally, two studies reported the augmentation and detection of low-frequency bands in the 1 kHz range during the late phase of stem insertion and final femoral broaching [2, 17].

Table 2 Key findings from studies evaluating the role of acoustic analysis in detecting implant stability and subsidence
Full size table

Intraoperative fracture detection

According to one study, minimal changes in the FRF graph produced during stem broaching could indicate implant stability (Table 3) [4]. In one case, the study observed an abnormal shape in the FRF graph, in which a minor fracture was immediately found. Another study associated a distinct sound alteration with the occurrence of a femoral fracture: immediately before bone fracture, the frequency and amplitude of the low-frequency band gradually increased and then diminished, the change coinciding with the fracture [17]. One study found that sharp decreases in BPF and PCC during the hammering sequence might serve as a warning for periprosthetic microfracture [14]. Additionally, two articles reported that intraoperative fracture could be prevented by stopping hammering when the peak frequency converges within ± 0.5 kHz during implant fixation across three consecutive blows [15, 16]

Table 3 Key findings from studies evaluating the role of acoustic analysis in detecting intraoperative fractures
Full size table

Factors affecting acoustic analyses

One study observed that the additional low-frequency band originated from inside the femoral canal itself, and thus, the frequency was related to bone length (Table 4) [17]. This finding was corroborated by another study, which revealed an association between the augmentation of low-frequency bands (0.5–1.5 kHz) and stature-related morphological features such as height, weight, and femoral shaft length (FSL) [2]. Another study discerned that femoral morphological features such as Canal-calcar ratio (CCR), Canal-flare index (CFI), Morphologic cortical index (MCI), and FSL influenced hammering sounds in addition to the type of cementless implant used [1]. One study found no association between the recorded frequency and cortical thickness, BMI, or medullary canal diameter [17]. In addition, one study reported that acoustic analysis was more likely to detect hammering sounds at a position near the patient's head as opposed to the left or right side of the body [15].

Table 4 Key findings from studies evaluating variance in acoustic profiles emitted per implant and patient characteristics
Full size table

Accuracy of predictive models via acoustics

In one study, a model, developed using machine learning techniques, was able to distinguish the final rasping hammering sound with high accuracy (Table 5). Notably, a higher degree of accuracy was noticed with models that analyzed datasets using only 1 implant type (rather than 2 or more). Furthermore, the models performed better at differentiating between acoustic profiles emitted when they were dealing with larger differences in the stem size [7]. Also, another study discussed the innovation of a support vector machine learning algorithm that could predict postoperative subsidence with high accuracy. Adding additional features, such as the patients' basic background features and femoral morphological parameters to nSP (Normalized sound pressure), raised the accuracy of models to nearly 100% [20]. A diagnostic test with a sensitivity of 83.3%, specificity of 81.8%, positive predictive value of 97.4%, and negative predictive value of 37.5% was created using the augmentation of low-frequency bands as an indicator of correctly sized implants [17]. A prediction model for postoperative stem subsidence, as reported in a study in 2022, demonstrated a positive predictive value of 100% and a negative predictive value of 90.6% for postoperative stem subsidence at 5 mm or more [18].

Table 5 Key findings from studies evaluating the accuracy of predictive models generated via acoustic analysis
Full size table

Discussion

Despite recent advancements with THA, there is a need for a more objective evaluation to assist an orthopedic surgeon in identifying the insertion endpoint of the broaching procedure. A multitude of biomechanical and in-vitro studies have demonstrated the promising potential of acoustic and vibration analyses for THA. We conducted this systematic review to evaluate the in-vivo efficacy of various acoustic and vibration models. Across methodologies used to evaluate acoustic profiles, analyses have suggested stopping broaching when consecutive blows emit similar acoustic profiles, which indicates proper implant seating for stability and minimizing subsidence. Also, large deviations from the typical progression of acoustic signals while broaching imply that an intraoperative fracture occurred. As patient characteristics and implant-specific parameters have been shown to alter acoustic emissions while hammering, the incorporation of these factors into models to predict subsidence or intraoperative fracture results in increased accuracy in identifying these adverse events.

Implant stability detection

Augmentation of low-frequency bands (around 1 kHz), stabilization of maximum peak frequency, and increased correlation of FRF during the last two hammer impactions indicate appropriate implant fixation. The quantitative evaluation of the hammering sounds may be a future standard as it is objective, non-invasive, and accurate, as opposed to the auditory sensations of the surgeon, which are subjective [2]. Widespread application of this approach could lead to healthcare savings in addition to successful implantation, as accurate implant sizing mitigates subsidence, migration, and aseptic loosening, which are responsible for practically 50%–60% of revision THAs [22]. One study observed that aseptic loosening within two years was likely due to inadequate implant fixation and poor press fit, with 17% of implant revisions performed before two years [4, 23]. The usage of acoustic analysis may minimize these adverse outcomes after THA, due to its superior detection of implant fixation. Despite the promising results, the use of acoustics for detecting implant stability still needs further study and standardization with respect to methodology, patient population, and acoustic parameters. In addition, the correlation between achieved THA implant stability and clinical outcomes, such as pain relief and functional improvement, should be investigated.

Intraoperative fracture detection

Current literature indicates that any large deviation from the normal progression of acoustic parameters while hammering might indicate an intraoperative fracture or crack. For instance, sudden attenuation of low-frequency bands in frequency and amplitude implies the occurrence of a fracture [17]. Intraoperative fractures complicate the surgery with prolonged operative time and recovery, inferior outcomes, and an increased risk of revision surgery [24]. Acoustic monitoring may mitigate this burden as surgeons can stop implant impaction when acoustic profiles change. Fractures that go undetected or untreated intraoperatively cause delayed weight bearing, which sometimes requires complicated management strategies and may necessitate complex reoperations. According to a retrospective case series of 6350 THAs, the incidence of undetected intraoperative periprosthetic femoral fractures (IPFFs) was 0.38%, with a reoperation rate of 30.4% [25]. Early recognition of such fractures is integral for optimizing management. While no studies included in this analysis investigated distinctions among different fracture patterns or for acetabular fractures, it has been observed that intraoperative acetabular fractures were rare compared to stem fractures, with an incidence of only 0.4% in cementless cups [26, 27]. Neither did the studies have enough power to evaluate whether surgical approach influenced fracture rates and subsequent acoustic detection, but they have suggested that using minimally invasive or direct anterior approaches during the surgeon’s learning curve are risk factors for intraoperative fracture [28,29,30,31]. The application of acoustic analysis can be tailored specifically towards distinguishing fracture patterns to improve rates of detection and better understand the complication profile associated with various techniques.

Factors affecting acoustic analyses

Sound alteration during broaching is influenced by multiple factors, such as patient stature, femoral morphological characteristics, and implant type. Specifically, one study concluded that particular attention must be paid to people with short stature as they may exhibit a relatively small acoustic change during stem insertion [2]. This may be attributed to the fact that the femur is heavier than the stem, thereby becoming the main vibrating object and the primary source of acoustic emission [2, 17]. In addition, with numerous implant options available to surgeons, the natural frequency and acoustic emittance shapes emitted during broaching are specific for each implant [1,2,3]. Manufacturers of hip prosthetic implants may elect to report the natural frequency of their implants to assist surgeons in adopting acoustic monitoring during THA. Lastly, further research into how the force of impaction and the resultant slight deformations can lead to different acoustic emissions merits further investigation [32].

Accuracy of predictive models via acoustics

Although numerous implant and patient-specific parameters influence the variability of acoustic profiles, these limitations can be mitigated by implementing artificial intelligence (AI), machine learning, and other predictive models in sound analysis. Acoustic models using machine learning and AI have demonstrated nearly 100% accuracy in detecting postoperative subsidence [18, 20]. Currently, surgeons subjectively determine when proper implant insertion has been attained through rough auditory and tactile cues. While advances have been made in assisting surgeons in determining the optimal positioning of implants with robotic-assisted and computer-navigated platforms, [33,34,35] acoustic analyses may offer a similarly more accurate, objective, and non-invasive method to detect proper implant fixation.

Limitations

This study is not without limitations. The included studies were mostly of an observational nature and did not compare to patient cohorts who underwent THA without acoustic analyses. Likewise, we were unable to control for surgeon experience with THA. Less experienced surgeons may have higher rates of intraoperative fracture and reduced implant stability. Third, there was considerable heterogeneity among studies regarding microphones, sample frequency, spectral analyzer software, and approaches to quantifying the acoustic emissions, leading to difficulty comparing the utility of acoustic analyses across studies. Fourth, many studies had limited sample sizes, as a result, they may have been underpowered to detect the benefits of acoustic emission analyses. Fifth, no studies commented on the relationship between the frequency of blows and implant stress relaxation regarding its possible effect on stability and fracture.

Conclusions

At present, there is no well-accepted diagnostic tool for predicting implant stability. This review discussed the clinical application of acoustic and vibration analysis during THA. Although studies have demonstrated the benefits of acoustic analyses in detecting proper implant seating and intraoperative fractures and predicting subsidence, further research into the clinical outcomes and long-term implant success in the long run is warranted.

Data availability

Data is available upon request to the corresponding author.

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Acknowledgements

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Funding

This work was supported by JSPS KAKENHI Fostering Joint International Research (A) Grant Numbers 21KK0281. This work is also supported by Grant-in-Aid for Science Research from the Japanese Society for Replacement Arthroplasty Foundation, No 2023-RP03.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, B.J. Medical College, Ahmedabad, Gujarat, 380016, India

    Shlok Patel

  2. Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA

    Christian J. Hecht II & Atul F. Kamath

  3. Department of Medicine for Orthopaedics and Motor Organs, Juntendo University Graduate School of Medicine, Bunkyo-Ku, Tokyo, 113-8421, Japan

    Yasuhiro Homma

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Contributions

S.P. and C.J.H. were involved in data curation, formal analysis, investigation, methodology, validation, visualization, writing—original draft, writing—review, and editing. Y.H. and A.F.K. were involved in conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, supervision, validation, visualization, writing—original draft, writing—review, and editing.

Corresponding author

Correspondence to Atul F. Kamath.

Ethics declarations

Ethics approval and consent to participate

All data included in this study were publicly available and did not include protected health information. Therefore, this study was considered exempt from ethical review board approval.

Consent for publication

Not applicable.

Competing interests

A.F.K. reports the following disclosures: paid presenter or speaker (Zimmer Biomet), paid consultant (Zimmer Biomet, BodyCad, Ortho Development, United Ortho), stock or stock options (Zimmer Biomet, Johnson & Johnson, and Procter & Gamble), IP royalties (Innomed), and board or committee member (AAOS, AAHKS, and Anterior Hip Foundation). Y.H. reports the following disclosures: paid presenter or speaker (Zimmer Biomet Japan, B. Braun Aesculap, Smith and Nephew), paid consultant (Zimmer Biomet Japan, Kyocera, and Teijin Nakashima Medical). S.P. and C.J.H. have nothing to disclose.

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Patel, S., Hecht, C.J., Homma, Y. et al. What is the clinical utility of acoustic and vibrational analyses in uncemented total hip arthroplasty?. Arthroplasty 6, 59 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s42836-024-00280-0

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Arthroplasty

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