Femoral Stem Placement for Total Hip Arthroplasty Using Three-Dimensional Custom Surgical Guides in Dogs: A Cadaveric Study

Abstract

Objective The aim of this study was to assess the feasibility and accuracy of femoral stem placement for total hip arthroplasty (THA) using three-dimensional (3D)-printed custom surgical guides (CSGs).
Study Design Computed tomography (CT) scans of 7 cadaveric adult medium-sized (23.2–30.0 kg) dog femurs were acquired. A virtual plan was made using 3D models, and CSGs were designed to aid in optimal femoral stem positioning. Two surgeons with limited experience in THA performed stem implantation with CSGs for each limb. Following stem implantation, CT scans were repeated, and final stem alignment was measured and then compared with the preoperative virtual plan.
Results The median difference between planned and postoperative stem alignment with CSGs was –6.2 degrees (interquartile [IQR] –15.2 to 2.1 degrees) for stem version, 2.3 degrees (IQR –0.6 to 3.9 degrees) for varus/valgus angulation, and 1.8 degrees (IQR –0.1 to 2.9 degrees) for cranial/caudal stem angulation. The median difference in stem depth was 1.5 mm (IQR –1.2 to 3.1). Mean surgical procedure time for CSG surgeries was 44.1 ± 20.5 minutes for femoral stem implantation.
Conclusion The use of CSGs resulted in successful femoral stem placement by two novice THA surgeons. Novice THA surgeons may benefit from CSGs in the learning stages of THA, but further investigation is recommended prior to clinical implementation.

Full text

Femoral Stem Placement for Total Hip
Arthroplasty Using Three-Dimensional Custom
Surgical Guides in Dogs: A Cadaveric Study
Jose Carvajal1Sarah Timko1Stanley E. Kim1Daniel D. Lewis1Hae Beom Lee2
1DepartmentofSmallAnimalClinicalSciences,UniversityofFlorida,
College of Veterinary Medicine, Gainesville, Florida, United States
2Department of Veterinary Surgery, Chungnam National University,
Yuseong-gu, Daejeon, The Republic of Korea
VCOT Open 2024;7:e80–e86.
Address for correspondence Jose Carvajal, DVM, MS, DACVS-SA,
Department of Small Animal Clinical Sciences, University of Florida,
College of Veterinary Medicine, Gainesville, FL 32611, United States
(e-mail: josecarvajal@ufl.edu).
Introduction
Total hip arthroplasty (THA) is a well-accepted treatment
option for a variety of hip disorders in dogs.1While the overall
success rates range from 80 to 98% and can lead to excellent
surgical outcomes, major complications requiring additional
surgery are common.2–4Many of these complications are
related to imprecise execution of the procedure, particularly
for the femoral component (stem).5Accurate stem orientation
and the level of the femoral head ostectomy (FHO) are impor-
tant factors for the reduction of complication rates,3as poor
stem alignment can increase the risk of intraoperative com-
plications such as fissuring or fracture, or placement of an
undersized stem predisposing to subsidence with subsequent
luxation or fissuring/fracture.1–6
Surgical proficiency in THA in dogs is associated with a
steep learning cur ve.7,8 Consequently, inexperienced sur-
geons or low-volume surgeons have an increased chance of
encountering complications. Interestingly, evidence that re-
duction in complication rates may not be directly correlated to
increasing individual surgeon’s experience has also been
published.9Furthermore, the known challenges associated
Keywords
►total hip arthroplasty
►total hip replacement
►total joint
replacement
►3D-printed guides
►dog
Abstract Objective The aim of this study was to assess the feasibility and accuracy of femoral
stem placement for total hip arthroplasty (THA) using three-dimensional (3D)-printed
custom surgical guides (CSGs).
Study Design Computed tomography (CT) scans of 7 cadaveric adult medium-sized
(23.2–30.0 kg) dog femurs were acquired. A virtual plan was made using 3D models,
and CSGs were designed to aid in optimal femoral stem positioning. Two surgeons with
limited experience in THA performed stem implantation with CSGs for each limb.
Following stem implantation, CT scans were repeated, and final stem alignment was
measured and then compared with the preoperative virtual plan.
Results The median difference between planned and postoperative stem alignment
with CSGs was –6.2 degrees (interquartile [IQR] –15.2 to 2.1 degrees) for stem version,
2.3 degrees (IQR –0.6 to 3.9 degrees) for varus/valgus angulation, and 1.8 degrees (IQR
–0.1 to 2.9 degrees) for cranial/caudal stem angulation. The median difference in stem
depth was 1.5 mm (IQR –1.2 to 3.1). Mean surgical procedure time for CSG surgeries
was 44.1 20.5 minutes for femoral stem implantation.
Conclusion The use of CSGs resulted in successful femoralstem placement by two novice
THA surgeons. Novice THA surgeons may benefit from CSGs in the learning stages of THA,
but further investigation is recommended prior to clinical implementation.
received
April 8, 2024
accepted after revision
May 15, 2024
DOI https://doi.org/
10.1055/s-0044-1787746.
ISSN 2625-2325.
© 2024. The Author(s).
This is an open access article published by Thieme under the terms of the
Creative Commons Attribution License, permitting unrestricted use,
distribution, and reproduction so long as the original work is properly cited.
(https://creativecommons.org/licenses/by/4.0/)
Georg Thieme Verlag KG, Rüdigerstraße 14, 70469 Stuttgart,
Germany
Original Article
THIEME
e80
Article published online: 2024-06-25

with press-fit THA have led to the implementation of adapta-
tions such as prophylactic cerclage and/or plating, use of
hybrid components, as well as proprietary system adaptations
such as collars and interlocking lateral bolts to minimize the
incidence of some common complications.10,11
The role of computer-assisted design (CAD) software in
surgical planning, surgeon training, custom surgical guide
(CSG) development, and robotic-assisted surgery is quickly
expanding in human arthroplasty.12–15 CSGs have been used
in veterinary medicine and have showed improved surgical
accuracy in a wide variety of applications,16–20 but to our
knowledge, no study has assessed virtual arthroplasty plan-
ning or CSGs for THA in dogs.
The purpose of this cadaveric study was to determine
whether CAD software could be used for virtual femoral
stem templating and to assess the feasibility and accuracy of
three-dimensional (3D) CSGs for stem placement by inexperi-
enced THA surgeons in cadaveric dogs. We hypothesized that
CAD software could be used to successfully plan femoral stem
size, that stem alignment would be within acceptable ranges.5
Materials and Methods
Preoperative Planning
Seven medium to large mixed breed dogs that were eutha-
nized for reasons unrelated to the study were used. This study
was approved by the institutional animal care and use
committee (#201910714). Following euthanasia, Computed
tomographic (CT) scans of the pelvis and hindlimbs were
acquired, dogs werethen kept fresh in a cooler at 4°C following
imaging prior to surgery during CSG development. Digital
Imaging and Communications in Medicine (DICOM) files
were segmented, volume rendered, and exported as stereo-
lithography files to the CAD software (3-Matic, Materialize N.
V., Leuven, Belgium) for virtual planning. In addition, concur-
rent 3D models of press-fit cementless femoral stems (BFX,
Biomedtrix, Boston, Massachusetts, United States) were avail-
able for templating using the same software. A modified
femoral stem virtual plan using CAD software was executed
following current published guidelines.21 Once the virtual
surgical plan was determined satisfactory by an experienced
THA surgeon (Stanley Kim) (►Fig. 1), the virtual ostectomy
and virtual femoral broaching guides were designed.
Virtual Guide Design and Printing
The ostectomy guide was created with features that would
help ensure secure attachment to the femur and precise
ostectomy location (►Fig. 2). The broaching guide was
designed to assist in canal preparation starting with initial
entry point drilling of the trochanteric fossa, reaming,
broaching, and final stem placement (►Fig. 3).
All components were fabricated in ABS-M30i (Stratasys,
Eden Prairie, Minnesota, United States) using a Fortus 450MC
printer (Stratasys) using a biocompatible, production-grade
thermoplastic (ABS M30i, Stratasys Inc).
Surgical Procedure
The surgical procedures were performed by a first-year small
animal surgery resident (Jose Carvajal) and a board-certified
surgeon (Daniel Lewis). Neither individual had previous ex-
perience as a primary surgeon with cementless THA. Each
surgeon operated on femurs for each dog at random using the
CSGs thereby modifying the traditional technique as previ-
ously described.21 Surgical assistance was provided by one
Fig. 1 Virtual plan. Modified vir tual templating plan using three-dimensional rendered models of cadaveric femur and press-fit femoral stem in
the coronal (A), sagittal (B), and axial (C)plane.
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veterinary student (Sarah Timko) who had no prior experi-
ence with THA, and a small animal surgeon (Hae Lee) who had
significant experience with Zurich Cementless THA system
(Kyon Veterinary Surgical Products, Boston, Massachusetts,
United States). For each procedure, dogs were placed in lateral
recumbency, the surgical leg was clipped with a number 40
blade and draped, and a routine craniolateral approach to the
hip was performed.21 Craniocaudal and lateromedial views of
the 3D digital bone model and virtually implanted stem
(including size of the stem) were available to the surgeon
intraoperatively. The pelvic muscularity of each cadaveric dog
was determined on a scale from 1 (severe atrophy), 2 (mild
atrophy), 3 (normal), to 4 (very muscular).
For the modified CSGs procedures, the ostectomy guide
was placed on the cranioproximal femoral head and neck. A
partial “take-down”of the vastus lateralis along the cranial
aspect of the greater trochanter was performed to allow
proper placement of the CSGs. The guide’sfit was confirmed
to be flush with the femoral head and neck at the proximal,
distal, medial, and lateral aspects of the guide and was
secured into place with Kirschner wires. The ostectomy
was created by keeping the saw blade in contact with the
cutting shelf (►Fig. 4A). Once completed, the two trochan-
teric Kirschner wires were left in situ for placement of the
broaching guide. The broaching guide was placed over the
trochanteric Kirschner wires and secured in place with an
additional trochanteric post. Proper fit was confirmed when
the guide’s safety shelf sat flush with the osteotomy surface.
After initial drilling with a 5-mm drill bit, the drill post was
cut and removed for subsequent reaming and broaching. The
femoral broach was aligned by the surgeon using the broach-
ing guide’s alignment posts as a reference in the coronal,
sagittal, and axial planes (►Fig. 4B). Placement of both
guides was subjectively graded by each surgeon as easy,
moderate, or difficult. Procedural advice during the ostec-
tomy, reaming, or broaching by either assistant during CSGs
procedures was not permitted. Final stem size was planned
Fig. 2 Virtual ostectomy guide and plan. The guide was contoured to
the femoral head and neck and designed to be secured into place with
two converging Kirschner wire (k-wire) slots (adjacent to white
asterisk), and two parallel trochanteric slots for added stability
(adjacent to black asterisk). The cutting shelf has a 1-mm slot at an
equivalent plane to the preplanned ostectomy (white arrowhead),
with an “trochanteric overhang”cutting shelf when indicated (black
arrowhead). (B) The ostectomy plane (green) is flush to the shoulder
of the press-fit stem (blue) ensuring adequate room between the
stem and cortical bone in the craniomedial plane.
Fig. 3 Virtual femoral broaching guide. (A) The guide is contoured to the calcar region following ostectomy of the femoral head and neck.
It features the same two parallel trochanteric posts (adjacent to black asterisk) in (Fig. 2A) with a single converging post (white asterisk)
for added stability. A drill post was designed for guiding of the initial entr y point into the trochanteric fossa (black arrow), an aiming post
intended to provide the surgeon with the ideal sagittal and coronal stem axiality (white arrowhead), a shorter “version”shaft positioned
on the aiming post (black arrowhead), and a broaching “safety shelf”(white arrow) resting on the ostectomy surface (green) with a
crescent-shaped component corresponding to the idealcentralpositionoftheterminalbroachandstem.(B) The aiming post is coaxial to the
stem (blue) in the coronal plane. (C) The aiming post is coaxial to the stem in the sagittal plane. (D) The version shaft is 90 degrees to the stem
orientation in the axial plane, and the drill post marks the ideal drilling location based on the center of the stem.
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based on preoperative template or when contact was made
between broach and medial aspect of the safety shelf
(►Fig. 4C). After the stem placement was completed, the
femur was dissected from the surrounding tissue for post-
operative CT imaging.
The time was recorded for each component of the proce-
dures including: the approach (skin incision to the exposure
of the femoral head and neck), guide placement (placement
of the guides on the femur until they were secured with
Kirschner wires), the ostectomy, canal preparation (initial
drilling to terminal broaching), and stem placement (stem
placement until press-fit is achieved).
CT Analysis and Data Collection
CT scans of the femurs with implanted stems were acquired,
and the DICOM images were exported to the CAD software
3-Matic. The postoperative CT images were measured and
compared with the preoperative plan by superimposing
the pre- and postoperative femurs using a translational
function and calculating the degree of difference between
the two implants in the x,y,andzplanes (►Fig. 5). The
variables assessed included stem angulation in the coronal
(Stem
cor
) plane with negative values indicating varus, in the
sagittal (Stem
sag
) plane with negative values indicating
cranial angulation, and in the axial (Stem
ax
)planewith
negative values indicating normo-version or retro-version
(>15 degrees). Additionally, s tem depth and the Hausdor ff
distance (HD), which is defined as the degree of mismatch
between two data sets, were used to assess the degree of
positioning error between the preoperative and postopera-
tive models.
Statistics
For continuous numeric data, normality was evaluated using
the Shapiro–Wilk test. Continuous, numeric nonparametric
data sets were summarized as median and range. Differences
between surgeons were not investigated.
Results
Surgical Procedure
Seven BFX femoral stem implants were placed in seven
medium to large mix breed cadavers, with average body-
weight o f 25.6 kg (3.6). Five stems of the correct size were
inserted, while two were undersized compared with preop-
erative planning. Results of individual dog’s muscularity,
difficulty of guide placement, total surgical time (minutes),
maximum HD, vir tual stem size, and final stem size are l isted
in ►Table 1. Mean surgical procedure time for CSG surgeries
was 44.1 20.5 minutes.
CT Analysis
Results for stem alignment are available in ►Fig. 6.The
median difference between planned and postoperative
stem alignment with CSGs was –6.2 degr ees (interquartile
[IQR] –15.2 to 2.1 degrees) for stem version, 2.3 degrees (IQR
–0.6 to 3.9 degrees) for varus/valgus angulation, and
1.8 degrees (IQR –0.1 to 2.9 degrees) for cranial/ caudal
stem angulation. The median difference in stem depth was
1.5 mm (IQR –1.2 to 3.1). The mean HD difference was 0.68.
Discussion
The implementation of a virtual plan and use of CSGs was
feasible for femoral stem implantation in all cadavers. Fur-
ther investigation should be considered for the use of CSGs as
they may be useful for inexperienced TH A surgeons. The final
stem position was acceptable in all cases, and no major
intraoperative complications occurred during the femoral
preparation process.
Fig. 4 Intraoperative images. (A) The sagittal saw blade is sitting flush to the cutting shelf while performing the ostectomy. (B)Thefemoral
broach is coaxial to the aiming post, and the version shaft is coaxial to the cemented stem impactor. (C) Final stem implantation with the
femoral broaching guide on. Note the drill post is removed following initial drilling.
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The ability to accurately predict implant size for THA is of
paramount importance.1–12 In this study, the implanted
stem size matched the virtual plan exactly in 5/7 femurs,
and was within one size in the remaining 2 femurs. In the two
procedures in which the final stem size was one size smaller
than the virtual plan, the smaller stem was selected intra-
operatively because the broach met with the safety shelf of
the broaching guide. Additionally, these two stems were
malaligned in the frontal and sagittal planes. Therefore, the
down-sized stems in the two cases reflect issues with canal-
prep execution, rather than inconsistent preoperative plan-
ning. In addition to predicting stem size, this 3D virtual plan
allowed for assessment of coronal, sagittal, and axial posi-
tioning of the femur for each case. This approach therefore
overcomes the limitations of radiography, which can lead to
variability associ ated with positioning of the femur.5Altering
stem anteversion changes the concurrent two-dimensional
geometry of the stem in the coronal and sagittal plane, and
this is not accounted for with traditional radiographic tem-
plating. Although the pur pose of the present study was not to
compare the accuracy of the CAD virtual plan in predicting
implant size to an accepted method of templating, such a
comparison study may be warranted.
This study aimed to explore the feasibility of CSGs for THA,
with the long-term goal of determining realistic applications
and capabilities of CSGs in the clinical setting. The ostectomy
guide was designed to ensure a smooth and controlled ostec-
tomy height and orientation. In this study, characteristics of
the ostectomy were not able to be adequately assessed due to
image scatter artifact from the impacted stems in the postop-
erative models. The attempt to interpret variablessuch as stem
height and HD distances to assess the ostectomy were
Fig. 5 Postoperative stem alignment assessment. Superimposed virtual plan (blue) and postoperative (red) stem models over the preoperative cadaveric
femur model. Using a translational feature, The Hausdorff distance (HD) between the two implants in the coronal (A), sagittal (B), and axial (C)
orientations was assessed. Note that the red stem is smaller (one size) due to the degree of varus and caudal malalignment.
Table 1 Resultsofindividualdog’smuscularity
Dog Muscularity Guide placement (ostectomy/broaching) Surgical time (min) Virtual stem size Final stem size
14 Easy/difficult 52.7 9 9
22 Easy/easy 33.5 8 8
3 3 Easy/moderate 40.8 7 7
44 Moderate/difficult 50.4 8 7
53 Easy/difficult 47.7 9 9
61 Easy/easy 32.1 8 8
74 Easy/difficult 51.6 10 9
Note: Results of individual dog’smuscularity(1¼severe atrophy, 2¼mild atrophy, 3 ¼normal, 4 ¼very muscular), difficulty of guide placement,
total surgical time, virtual stem size and final st em size. ( mm) ¼millimeter.
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ultimately not pursued due to the low number of cases, type 2
error, and the variability in virtual and final stem sizes in two
cases. However, the use of the ostectomy guide was easy, fast
when compared with the broaching guide, and subjectively
added a significantdegree of confidence. In the clinical setting,
CSGs may be especially useful in cases with severe secondary
changes and distorted anatomical landmarks.
The broaching guide was designedto give the surgeonvisual
references for controlling stem alignment in all three planes,
rather than relying on assistant’s visual references (in the
sagittal plane). In our postoperative analysis, Stem
ax
had the
greatest degree of error, where there was a tendency to place
the stems in normo-version rather than the planned ante-
version, which may predispose to changes in gait and medial
patellar luxation in clinical patients. The potential reason why
version was most inaccurate despite the availability of a
version shaft is that normo-version is generally the path of
least resistance during broaching, and small deviations from
the plan are difficult to observe intraoperatively.
One potential benefit of the design explored in this study
was the ability for the surgeon to rely solely on the broaching
guide for alignment in all three planes. Clinical cases with
excessive femoral procurvatum may benefit from CSGs as an
alternative to relying on an assistant to determine sagittal
alignment. Another feature of the broaching guide, its safety
shelf, was created with the intention to help preserve
craniomedial bone stock by giving a visual “warning”to
the surgeon to lateralize broaching/rasping. However, canal
preparation still requires an active effort that requires haptic
feedback and early recognition of malalignment currently
only gained through experience, something that was not able
to be overcome by the safety shelf, as evident in two guided
cases that required implantation of a smaller stem due to
interference with the safety shelf.
The rationale for including an experienced board-certified
surgeon and a resident was an attempt to demonstrate the
accuracy of the guides in a representative spectrum of
potential novice THA surgeons, rather than to distinguish
differences between the two surgeons. A conflicting factor is
that the resident (Jose Carvajal) was the primary designer of
the guides and gained substantial familiarity with the press-
fit system and procedure through the design process. Possi-
ble alternative study designs may demonstrate notable
differences between surgeons, or between guided or free-
handed procedures, especially if an independent guide de-
signer is excluded from the surgical procedure.
The wide range in surgical time can be contributed to the
additional t ime for soft tissue disse ction and ensuring proper
fit of the guides, especially the broaching guide. The longest
surgeries were docu mented in the heavily muscled dogs with
prominent quadriceps and gluteal musculature, which re-
quired a relatively more extensive vastus take-down, and
imposed challenges by interferi ng with the drill post pos ition
of the broaching guide. In the clinical setting, patients with
notable pelvic limb muscular atrophy may be better candi-
dates for CSGs given the subjective easier fit and shorter
Fig. 6 Degree of error between pre- and postoperative implant placement. Each data point represents the degree of error measured for an
individual dog (yellow ¼dog 1, red ¼dog 2, blue ¼dog 3, purple ¼dog 4, black ¼dog 5, green ¼dog 6, gray ¼dog 7).
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surgical times of dogs with low muscularity scores in this
study.
There are several limitations to our study: Cadaveric dogs
do not adequately replicate many factors affecting femoral
preparation and stem implantation that may be encountered
in clinical cases. Additionally, only one guide design (one
ostectomy and one broaching guide) was tested. Further-
more, the study was not sufficiently powered to find indi-
vidual differences between surgeons, and despite surgery
being performed by novice surgeons, the planning was
verified by an experienced arthroplasty surgeon, likely af-
fecting outcomes. Finally, potential benefits of 3D-printed
guides should be weighted against the increased financial
costs and the possibility of potential complications associat-
ed with increased surgical times, such as periprosthetic joint
infections.22 It should be mentioned that CSGs may give the
false idea that the surgery is more accessible and can be
performed without prior experience. Instead, the perfor-
mance of these surgeries with CSGs requires considerable
expertise, familiarity with the multiple anatomical, patho-
logical, and CSG variables, as well as the ability to make
unplanned intraoperative decisions. Ultimately, it is likely
that this cohort is not reflective of some of the challenges
encountered in clinical cases as the use of cadavers allows for
less soft tissue resistance, better exposure and elevation of
the femur, and lack of bony/periarticular pathology that
affects stem implantation in clinical cases.
In summary, CT-based virtual templating may be a prom-
ising preoperative tool for THA in dogs, and implementation
of CSGs resulted in acceptable accuracy of femoral stem
placement without the occurrence of major intraoperative
complications. Further investigation in the use of 3D model
templating and the application of 3D CSGs by novice THA
surgeons is encouraged prior to clinical application.
Funding
None of the authors of this article has a financial or
personal relationship with other people or organizations
that could inappropriately influence or bias the content of
the paper.
Conflict of Interest
None declared.
Acknowledgments
This study was supported by the Edward DeBartolo Gift to
the University of Florida.
References
1Olmstead ML. Total hip replacement. Vet Clin North Am Small
Anim Pract 1987;17(04):943–955
2Ganz SM, Jackson J, VanEnkevort B. Risk factors for femoral
fracture after canine press-fit cementless total hip arthroplasty.
Vet Surg 2010;39(06):688–695
3Nelson LL, Dyce J, Shott S. Risk factors for ventral luxation in
canine total hip replacement. Vet Surg 2007;36(07):644–653
4Dyce J, Wisner ER, Wang Q, Olmstead ML. Evaluation of risk factors
for luxation after total hip replacement in dogs. Vet Surg 2000;29
(06):524–532
5Townsend S, Kim SE, Pozzi A. Effect of stem sizing and position on
short-term complications with canine press fit cementless total
hip arthroplasty. Vet Surg 2017;46(06):803–811
6Pernell RT, Gross RS, Milton JL, et al. Femoral strain distribution
and subsidence after physiological loading of a cemen tless canine
femoral prosthesis: the effects of implant orientation, canal fill,
and implant fit. Vet Surg 1994;23(06):503–518
7Hayes GM, Ramirez J, Langley Hobbs SJ. Use of the cumulative
summation technique to quantitatively assess a surgical learning
curve: canine total hip replacement. Vet Surg 2011;40(01):1–5
8Franklin SP, Miller NA, Riecks T. Complications with the Zurich
canine total hip replacement system in an initial series of cases
performed by a single surgeon. Vet Comp Orthop Traumatol 2021;
34(05):346–351
9Kidd SW, Preston CA, Moore GE. Complications of porous-coated
press-fit cementless total hip replacement in dogs. Vet Comp
Orthop Traumatol 2016;29(05):402–408
10 Israel SK, Liska WD. Outcome of canine cementless collared stem
totalhip replacementwith proximal femoral periprosthetic cerclage
application: 184 consecutive cases. Vet Surg 2022;51(02):270–278
11 Buks Y, Wendelburg KL, Stover SM, Garcia-Nolen TC. The effects of
interlocking a universal hip cementless stem on implant subsi-
dence and mechanical properties of cadaveric canine femora. Vet
Surg 2016;45(02):155–164
12 Schneider AK, Pierrepont JW, Hawdon G, McMahon S. Clinical
accuracy of a patient-specific femoral osteotomy guide in minimal-
ly-invasive posterior hip arthroplasty. Hip Int 2018;28(06):636–641
13 Chang JD, Kim IS, Bhardwaj AM, Badami RN. The evolution of
computer-assisted total hip arthroplasty and relevant applica-
tions. Hip Pelvis 2017;29(01):1–14
14 Kumar P, Vatsya P.R ajnish RK, Hooda A , Dhillon MS. Application of
3D printing in hip and knee arthroplasty: a narrative review.
Indian J Orthop 2021;55(Suppl 1):S14–S26
15 Pelliccia L, Lorenz M, Heyde CE, et al. A cadaver-based biomechan-
ical model of acetabulum reaming for surgical virtual reality
training simulators. Sci Rep 2020;10(01):14545
16 Hall EL, Baines S, Bilmont A, Oxley B. Accuracy of patient-specific
three-dimensional-printed osteotomy and reduction guides for
distal femoral osteotomy in dogs with medial patella lu xation. Vet
Surg 2019;48(04):584–591
17 Hamilton-Bennett SE, Oxley B, Behr S. Accuracy of a patient-
specific 3D printed drill guide for placement of cervical trans-
pedicular screws. Vet Surg 2018;47(02):236–242
18 Lynch AC, Davies JA. Percutaneous tibial fracture reduction using
computed tomography imaging, computer modelling and 3D
printed alignment constructs: a cadaveric study. Vet Comp
Orthop Traumatol 2019;32(02):139–148
19 Worth AJ, Crosse KR, Kersley A. Computer-assisted surgery using
3D printed saw guides for acute correction of antebrachial angu lar
limb deformities in dogs. Vet Comp Orthop Traumatol 2019;32
(03):241–249
20 Roh YH, Cho CW, Ryu CH, Lee JH, Jeong SM, Lee HB. Comparison
between novice and experienced surgeons performing corrective
osteotomy with patient-specific guides in dogs based on res ulting
position accuracy. Vet Sci 2021;8(03):40
21 BioMedtrix Inc. Canine Modular Total Hip Replacement System,
Surgical Protocol for BFX. Cementless Application. Boonton, NJ:
BioMedtrix Inc.; 2008
22 Scigliano NM, Carender CN, Glass NA, Deberg J, Bedard NA.
Operative time and risk of surgical site infection and peripros-
thetic joint infection: a systematic review and meta-analysis.
Iowa Orthop J 2022;42(01):155–161
VCOT Open Vol. 7 No. 1/2024 © 2024. The Author(s).
3D-Printed Subject-Specific Guides for Canine Total Hip Arthroplasty Carvajal et al.e86