Clinical Study on the Effects of Total Hip Arthroplasty Assisted by Virtual Planning Combined With Intraoperative Navigation Templates

Abstract

ABSTRACT

Objectives

Although total hip arthroplasty (THA) effectively alleviates pain and restores joint function in the end‐stage hip disease, challenges remain in achieving precise osteotomy and minimizing subjective dependency on prosthesis positioning. This study aims to evaluate the efficacy and safety of preoperative virtual planning and navigation templates compared to conventional techniques, providing new methods to enhance the precision and personalization of THA.

Methods

During the period from 2022 to 2023, we conducted a retrospective case–control study on 74 patients who underwent THA surgery at our hospital, based on the inclusion and exclusion criteria. The study included 42 patients in the traditional method group, who underwent preoperative planning and surgical procedures according to traditional methods; and 32 patients in the digital assistance group, who used computer‐assisted virtual preoperative planning and three‐dimensional printed personalized navigation templates to assist in the surgery. The main parameters of the two groups were compared, including surgical time, blood loss, postoperative femoral anteversion, neck‐shaft angle, anatomical‐mechanical femoral axis angle (aMFA), leg length discrepancy (LLD), and the angle of hip prosthesis placement. The Harris hip score was recorded both preoperatively and at the final follow‐up to assess the accuracy of the prosthesis placement and the prognosis of the patients.

Results

There were no significant differences in femoral anteversion, neck‐shaft angle, aMFA, or LLD between the two groups. However, the digital group showed smaller deviations between the planned and actual acetabular prosthesis angles compared to the conventional group, with shorter operative times and reduced blood loss. Follow‐up Harris hip scores were significantly higher in the digital group (p < 0.05).

Conclusions

Digital technology enhances the accuracy and reproducibility of prosthesis placement in THA, reduces operative time and blood loss, and shows a promising potential for broader application.

Abbreviations

• aMFA
• anatomical-mechanical femoral axis angle
• AR
• augmented reality
• ARCO
• Association Research Circulation Osseous
• CAD
• computer-aided design
• CAM
• computer-aided manufacturing
• CAN
• computer-assisted navigation
• CAOS
• computer-assisted orthopedic surgery
• CAS
• computer-assisted surgery
• LLD
• leg length discrepancy
• RAS
• robot-assisted surgery
• THA
• total hip arthroplasty
• VR
• virtual reality

Introduction

Total hip arthroplasty (THA) is an effective treatment for end-stage hip joint diseases, including osteoarthritis (OA), rheumatoid arthritis (RA), femoral head necrosis (FHN), pelvic fractures, traumatic arthritis, developmental dysplasia of the hip (DDH), and infectious arthritis. It also plays a significant role in pelvic tumor resection and reconstruction, as well as in hip revision surgeries, demonstrating significant advancements since its introduction in the 1960s [1]. By replacing damaged joint surfaces, THA restores function and improves quality of life. With an aging population and rising obesity rates, the global incidence of THA continues to increase [2]. While traditional THA effectively relieves pain and restores function, it lacks surgical precision [3]. Advances in digital technologies, including computer-assisted surgery (CAS) [4], robot-assisted surgery (RAS) [5, 6], and 3D printing [7], have been increasingly integrated into THA, greatly enhancing the procedure's precision and safety.

Digital technology has advanced significantly in medicine, particularly in surgical planning and simulation. For instance, 3D printing enables the creation of personalized surgical models and implants, facilitating precise preoperative planning and simulation [8]. Additionally, virtual reality (VR) technology offers immersive surgical simulation training, enhancing surgeon skills and reducing errors. Intraoperative augmented reality (AR) navigation systems provide precise positioning and improving surgical efficiency [9]. The application of these technologies has undoubtedly improved the outcomes of THA. However, they are also associated with significant limitations, such as high equipment costs, steep learning curves, and a tendency to focus on either preoperative planning or intraoperative navigation, rather than providing a seamless integration of both. This lack of continuity between planning and execution makes it challenging to ensure consistent outcomes for every procedure. Therefore, there is an urgent clinical need for a cost-effective and highly accurate technology to further enhance the precision and efficiency of THA.

Current clinical research on the combined effects of preoperative 3D planning and intraoperative precise navigation remains limited. Therefore, this study aimed to:

(i) Develop a novel THA auxiliary technique integrating computer-assisted preoperative planning with 3D-printed surgical guides to achieve seamless continuity between preoperative planning and intraoperative execution;

(ii) Compare this approach with conventional THA techniques to evaluate its impact on surgical outcomes and verify its efficacy and safety;

(iii) Benchmark this technique against other similar digital orthopedic technologies to analyze its advantages and limitations, providing new insights and practical guidance for the precise execution of THA.

Methods

Data Collection

This study is a retrospective case–control study. Based on the inclusion and exclusion criteria, 74 patients were selected for the study and were categorized into a conventional group (42 cases, 42 hips, 13 males, and 28 females, aged 65.97 ± 11.89 years) and a digital group (32 cases, 32 hips, 13 males, and 19 females, aged 61.79 ± 10.45 years) based on the application of digital technology aids or not (Tables 1,2). All surgeries were performed by the same experienced treatment team.

TABLE 1 General information (n = 74).

	Gender	Age/years	Side
Male	Female	—	Left	Right
Digital group	13	19	31–72 (65.97 ± 11.89)	18	14
Conventional group	13	28	45–95 (61.79 ± 10.45)	16	26
Pearson/T	0.417	1.607	0.241
p	0.627	0.112	0.624

TABLE 2 Information on primary hip diseases.

	Osteoarthritis	Necrosis of the femoral head	Femur fracture	Traumatic arthritis	Total
	ARCO III	ARCO IV	Intertrochanteric fractures	Femoral neck subcephalic fracture	Transcervical fracture of the femoral neck
Digital group	8	4	12	1	3	2	2	32
Conventional group	8	6	13	2	9	3	1	42
Total	16	10	25	3	12	5	3	74

The inclusion criteria included (i) patients diagnosed with hip osteoarthritis, end-stage osteonecrosis of the femoral head, or other advanced hip diseases requiring THA; (ii) age ≥ 45 years, with good physical condition capable of undergoing THA and postoperative rehabilitation; (iii) undergoing primary THA; (iv) consenting to virtual planning and intraoperative navigation template assistance for THA, with informed consent signed by the patient or their agent; and (v) postoperative follow-up of ≥ 6 months, with complete pre- and postoperative medical records and imaging data.

The exclusion criteria included (i) patients with severe renal insufficiency, severe heart failure, or other serious systemic diseases that cannot tolerate surgery; (ii) previous hip arthroplasty or major hip surgery on the affected side; (iii) unable to undergo necessary imaging examinations or incomplete medical records and imaging data due to any reason; and (iv) refusal of virtual planning and intraoperative navigation template assistance for THA.

This study has received ethical approval from the institutional ethics committee (K-2018-137-01) and fully complies with the guidelines of the Declaration of Helsinki. All patients participating in the study were fully informed and gave their consent.

Complete preoperative imaging data, including X-rays and CT scans, were available for all patients. The X-rays were anteroposterior pelvic views, and CT scans covered the area from the anterior superior iliac spine to the knee or ankle joint (slice thickness of 0.5–1.0 mm). The data from the patients in the conventional group were processed in a standard manner, with routine preoperative discussions conducted. For the digital group, the data were saved in Digital Imaging and Communications in Medicine (DICOM) format for preoperative virtual planning and navigation template design.

Preoperative Preparation

In the conventional group, preoperative discussions were conducted based on X-ray, CT, and other imaging data to determine the osteotomy plane, acetabular positioning, and prosthesis placement on a two-dimensional imaging plane.

In the digital group, the collected DICOM-format X-ray, CT, and other imaging data were imported into the MIMICS 21.0 software (Materialize, Leuven, Belgium) to create a 3D model from the pelvis to the knee or ankle joint. This model was then imported in STL format into ImageWare 13.0 software (developed by UGS Corporation, Plano, TX, USA), where the specific hip joint pathology was observed by rotating the model (Figure 1). Baseline reference lines such as the lowest point of the ischial tuberosity, the line connecting the centers of the femoral heads, and the mechanical axis of the femur were used to align and position the pelvis and femur into the standard anatomical position. This allowed for the measurement of anatomical parameters, osteotomy of the femoral neck, prosthesis placement, and the design of surgical guides.

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After precise alignment of the three-dimensional model, a simulation was conducted to match the acetabular prosthesis, enabling the prediction of the appropriate prosthesis size. The placement was simulated with an anteversion angle of 20° and an abduction angle of 40°. The optimal positioning was designed, followed by a preliminary assessment of the expected postoperative outcomes (Figure 2).

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Intraoperative Details

The patient was placed in the lateral position under general anesthesia. A posterolateral hip incision was made to expose the femoral neck and acetabulum.

Conventional group: Osteotomy and femoral bone marrow cavity medulla dilatating were performed based on experience. The acetabulum was ground, guided by anatomical landmarks such as the transverse acetabular ligament. After the stability of the prosthetic mold trial test was satisfied, the femoral stem and acetabular cup prostheses were implanted, followed by wound irrigation and closure.

Digital group: The acetabular grinding guide was fixed with Kirschner wires, and the acetabular rasp was guided to 20° anteversion and 40° abduction. The femoral head osteotomy and medullary cavity dilation were performed using preoperative guides (Figure 4). After the prosthesis tryout test, the final prostheses were implanted, followed by wound closure. Postoperatively, surgical time, blood loss, and imaging data were recorded. A 3D model was reconstructed to compare key angles between the two groups, including acetabular cup abduction/anteversion, femoral anteversion, and neck-shaft angles.

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Statistical Analysis

Data were analyzed using SPSS 22.0 (IBM Corporation, Armonk, NY, USA). Normally distributed variables were expressed as mean ± standard deviation and compared using paired t-tests. Nonnormally distributed data were expressed as medians (25th and 75th percentiles) and analyzed using the rank-sum test. Categorical data were compared using the chi-square test. A p-value < 0.05 was considered statistically significant.

Results

General Results

The two groups showed no significant differences in gender (p = 0.627), age (p = 0.112), or the affected hip side (p = 0.624), follow-up duration (p = 0.961), preoperative femoral anteversion (p = 0.879), femoral neck-shaft angle (p = 0.647), aMFA (p = 0.064), LLD (p = 0.151), or preoperative Harris score (p = 0.636), thereby minimizing the influence of confounding factors.

Clinical Results

Compared with the conventional group, the digital group demonstrated significant advantages in terms of shorter operative time (76.25 [70, 87.5] minutes, p < 0.001) and reduced intraoperative blood loss (100 [100, 112.5] mL, p < 0.001). Both groups achieved significant postoperative corrections in femoral anteversion, femoral neck-shaft angle, aMFA, and LLD, with no statistically significant differences between the groups, Indicates that the positioning angle and depth of the femoral stem prosthesis had similar results in both groups. However, in terms of acetabular cup placement, the digital group demonstrated significantly lower acetabular anteversion deviation (1.85 [1.55, 3.66] vs. 6.19 [3.54, 9.72], p < 0.001) and acetabular abduction deviation (1.13 [0.37, 2.50] vs. 4.24 [2.99, 7.04], p < 0.001) compared with the conventional group. This suggests superior precision in acetabular prosthesis placement in the digital group.

Complication

No complications were reported in either group during the follow-up period. However, at the final follow-up, the Harris hip scores showed a significant difference between the digital group and the conventional group (p = 0.014).

Discussion

In the field of THA, the combination of preoperative simulation and 3D-printed surgical guides represents a significant advancement in personalized and precision surgery. Compared to conventional THA, this study demonstrated notable improvements in operative time, intraoperative blood loss, acetabular implant positioning, and postoperative hip function recovery. The postoperative femoral anteversion, aMFA, and LLD correction showed no significant differences between the groups, indicating that both approaches effectively restored normal hip anatomy. This could be attributed to the maturity of femoral prosthesis placement in traditional THA or the fact that the design of the femoral guide focused solely on anteversion. Similarly, no significant differences were found in postoperative neck-shaft angles, likely due to the fixed angle of the femoral stem prosthesis, which does not change once implanted.

Compared with widely studied and applied technologies such as computer-assisted navigation (CAN), computer-aided design and manufacturing (CAD/CAM), RAS, VR, and AR, the combined use of preoperative simulation with 3D-printed guides offers distinct advantages.

Indications for THA

THA is a critical intervention for end-stage hip joint diseases. Osteoarthritis is characterized by degenerative changes in the bone and cartilage, leading to significant pain, stiffness, and functional impairment, especially during weight-bearing activities. When conservative treatments, such as nonsteroidal anti-inflammatory drugs and physical therapy, are ineffective, THA becomes an effective option for improving quality of life by alleviating pain and restoring joint function postoperatively [10]. RA, an autoimmune disease affecting multiple joints, results in persistent pain and limited mobility. While medications can partially alleviate symptoms, THA remains the definitive solution for restoring joint function, demonstrating efficacy in pain relief and correction of deformities [11]. FHN is a pathological condition caused by insufficient blood supply, and symptoms can be relieved early with medication and physical therapy, combined with bone grafting [12, 13], core decompression [14, 15], biomaterial transplantation [16], and exosome therapy [17] to minimize THA. When FHN is severe and symptoms do not improve, THA becomes the ultimate effective treatment option [18]. Hip fractures [19] and severe traumatic arthritis [20] are common in elderly patients, often involving damage to bone and cartilage, resulting in persistent pain, joint instability, and FHN. In these cases, THA can effectively restore joint function, shorten the length of bed rest, and reduce long-term complications. DDH can also benefit significantly from THA [21, 22], restoring joint stability and function. In cases of pelvic bone tumors, partial or total hip joint resection may be necessary, making THA an effective option for joint reconstruction and recovery [23, 24]. Moreover, THA is a crucial intervention for the treatment of joint damage caused by infection [25] and for hip revision surgery [26]. It effectively addresses issues such as septic arthritis, implant failure, and bone loss, significantly restoring joint function and effectively alleviating pain.

Direct Correlation Between Preoperative Planning and Intraoperative Execution

In this study, the integration of preoperative planning with 3D-printed surgical templates significantly reduced operative time, with the digital group averaging 76.25 (70, 87.5) minutes compared to 120 (100, 140) minutes in the conventional group (p < 0.001). This approach also ensured predictable surgical outcomes (Table 3). Computer-assisted orthopedic surgery (CAOS) typically relies on real-time imaging and navigation systems to improve the accuracy of implant placement, which can increase procedural complexity and duration. In challenging cases, surgeons frequently switch between imaging and operative tasks [27–29]. In contrast, this study utilized patients' imaging data for preoperative simulation and precise surgical planning, followed by the design and creation of surgical guides to direct osteotomy and implant positioning. These guides provide a stable and fixed reference during surgery, eliminating the need for complex real-time navigation systems and reducing procedural complexity [30]. This seamless transition from planning to execution surpasses the capabilities of both CAOS and conventional THA.

TABLE 3 Surgical outcomes.

	Digital group	Conventional group	T/Z	p
Follow-up (months)	15.88 ± 2.80	15.90 ± 2.42	−0.049	0.961
Surgery time (min)	76.25 (70, 87.5)	120 (100, 140)	−0.678	< 0.001
Intraoperative blood loss (mL)	100 (100, 112.5)	200 (150, 350)	−5.932	< 0.001
Preoperative harris score	40.53 ± 12.27	39.29 ± 10.23	0.476	0.636
Final follow-up harris score	90 (89, 92)	86 (85, 88.5)	−2.447	0.014

Advancements in Personalized Design

CAD/CAM technology has been crucial for designing and manufacturing THA implants, particularly in standardized and semicustom production. However, CAD/CAM systems typically focus on optimizing implant design rather than directly aiding in surgical planning [31, 32]. This study addresses this limitation by integrating patient-specific 3D imaging data for preoperative digital design, allowing for custom implants and precise intraoperative guidance with 3D-printed templates. This personalized approach overcomes anatomical variability in complex cases, improving implant accuracy and hip function. The study's simulation design, targeting a 20° anteversion [33, 34] and 40° abduction [35, 36], achieved a postoperative deviation of 1.85° (1.55, 3.66) for anteversion (p < 0.001) and 1.13° (0.37, 2.50) for abduction (p < 0.001), compared to 6.19° (3.54, 9.72) and 4.24° (2.99, 7.04) in the conventional group. This demonstrates the significant improvement in implant placement accuracy with preoperative simulation and 3D-printed guides, aligning with previous research findings [37, 38].

Economic Advantages Over Robotic-Assisted Surgery

RAS excels in precision and repeatability for THA, particularly in complex cases [39]. However, its high equipment and maintenance costs, along with the need for extensive surgeon training, limit its widespread adoption [40]. RAS preoperative planning requires a high degree of accuracy in imaging data, and any image distortion due to patient movement or insufficient resolution may negatively impact the accuracy of preoperative planning [41]. Also not all robotic systems are adequately adapted to unique anatomical variants, and some systems may lack customization features, which may affect the correct placement and fit of the prosthesis (Table 4) [42]. Surgical procedures require a certain amount of operating experience to become proficient at manipulating robotic devices, and for beginners, a lack of ability to accurately control the robotic arm may lead to intraoperative errors [43]. In addition, the application of robotic systems reduces the human haptic feedback of traditional surgery, making it difficult for surgeons to recognize potential problems during osteotomy or prosthesis implantation in a timely manner, which may increase the complexity and uncertainty of surgery [44, 45]. Finally, real-time changes in hip structures such as intraoperative soft tissue dynamic responses and changes in the relative position of the pelvis and femur may also interfere with the execution of the robotic system, which may have an impact on surgical outcomes [46]. In contrast, although this study incurred additional imaging costs, the use of 3D-printed surgical guides, made from low-cost photopolymer resin, remains economically viable. This approach does not require significant changes to surgical infrastructure or extensive training, and the guides are used only as intraoperative aids that can be adjusted in real time by the surgeon based on haptic feedback and anatomical changes. The cost-effectiveness and high return of this method suggest strong potential for broader application, especially in resource-limited settings.

TABLE 4 Prosthesis placement.

		Digital group	Conventional group	T/Z	p
Femoral anteversion (°)	Preoperative	10.85 (6.42, 18.82)	13.37 (4.78, 17.98)	−0.153	0.879
Postoperative	23.27 ± 8.89	21.54 ± 7.37	0.913	0.364
Neck-shaft angle (°)	Preoperative	118.01 (99.69, 128.10)	122.98 (111.80, 129.91)	−0.458	0.647
Postoperative	131.64 (127.54, 138.06)	132.30 (125.77, 135.45)	−1.342	0.180
aMFA (°)	Preoperative	5.26 ± 1.16	4.72 ± 1.26	1.884	0.064
Postoperative	5.60 ± 0.72	5.37 ± 0.74	1.299	0.198
LLD (mm)	Preoperative	2.70 (1.06, 6.90)	1.78 (0.42, 5.68)	−1.435	0.151
Postoperative	1.74 (0.92, 4.27)	1.89 (0.70, 4.42)	−0.033	0.974
Acetabular anteversion deviation (°)	—	1.85 (1.55, 3.66)	6.19 (3.54, 9.72)	−4.103	< 0.001
Acetabular abduction deviation (°)	—	1.13 (0.37, 2.50)	4.24 (2.99, 7.04)	−4.703	< 0.001

Direct Utility of Physical Guides in Surgery

VR and AR offer immersive 3D anatomical visualization for preoperative planning, enhancing understanding of patient anatomy and surgical pathways [47]. However, these technologies primarily serve as supplementary tools and have limited application during surgery [48]. In contrast, this study's computer-assisted approach integrates preoperative planning into actual surgical tools, providing direct intraoperative guidance [49]. The use of physical guides during surgery minimizes reliance on VR or AR, ensuring seamless translation of preoperative plans into precise and stable surgical execution.

Strengths and Limitations

The virtual planning combined with intraoperative navigation templates ensures continuity between planning and execution, offering a cost-effective alternative to robotic surgery. Unlike VR and AR systems, it enables personalized plans and provides 3D-printed guides for direct use.

However, the guides have limited flexibility for intraoperative adjustments. While preoperative imaging, such as CT or MRI, may slightly increase costs, these are minimal compared to the benefits. The time required for planning and printing may also restrict its use in emergencies.

Prospects of Clinical Application

This study utilizes computer-assisted surgical planning and customized surgical templates to ensure precise positioning and implantation angles for THA, especially for complex cases such as DDH and severe hip deformities. The technology is cost-effective, requiring only basic computers and 3D printers, making it ideal for widespread adoption in various healthcare institutions. By using this method, the repetitive steps of measurement, positioning, and adjustments in traditional surgeries are significantly reduced, improving surgical efficiency. It also decreases reliance on the surgeon's technical skill. With accurate 3D planning preoperatively and stable guidance provided by the template during surgery, this approach enhances surgical precision, minimizes complications and improves surgical success rates, leading to better postoperative recovery.

However, the process of preoperative 3D planning and the creation of customized templates is complex and time-consuming, which may increase preparation time and overall surgical costs. Although personalized templates reduce dependence on the surgeon's skill, in complex cases such as severe acetabular deformities or osteoporosis, the template may not perfectly fit the bone surface, causing some inevitable errors and potentially impacting surgical outcomes. Since the sample size in this study is small, further multicenter clinical trials are needed to accumulate more data and validate the effectiveness of customized surgical templates in diverse patient populations. This will support the broader application of this technology. With the advancement of artificial intelligence and 3D printing, the design and manufacturing of customized surgical templates are expected to become more efficient and precise. In the future, AI-assisted automated design could further improve surgical accuracy and postoperative results.

Conclusion

This study presents a method for precise hip acetabular component placement in THA, ensuring seamless preoperative planning and intraoperative execution. Compared to traditional methods and advanced technologies like RAS and VR/AR, 3D-printed surgical guides provide more direct, reliable guidance, enhancing surgical outcomes and efficiency. This technology holds promise for significant advancement in orthopedic surgery and personalized precision medicine.

Author Contributions

All authors contributed to the conceptualization and design of the study. H.W.D., H.Y., H.T.Z., K.C., and J.Y.W. were responsible for program implementation, data collection, and analysis. J.J.L., Y.J.L., S.X.F., and Y.D.Z. designed and optimized the surgical protocol. H.T.Z. initially drafted the manuscript, which was subsequently reviewed and revised by all authors to produce the final draft. All authors acknowledge their responsibility for all aspects of the manuscript and the study.

Acknowledgments

The authors have nothing to report.

Ethics Statement

Ethics approval and consent to participate. Informed consent was obtained from all individual participants included in the study, this retrospective study involving human participants adhered to the ethical standards set by the Institutional and National Research Councils, as well as the 1964 Helsinki Protocol and its subsequent amendments or any other comparable ethical standards. The study was also approved by the First People's Hospital of Guangzhou (K-2018-137-01).

Consent

All authors agreed and ultimately finalized the manuscript, and all authors agreed to the article being published in Orthopaedic Surgery and acknowledged responsibility for all aspects of the manuscript and the research.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

All data generated or analyzed during this study are included in this published article and specific detailed data are available from the corresponding author upon reasonable request.

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