##### Monitoring cementless femoral stem insertion by impact
The primary stability of the femoral stem (FS) implant determines the surgical success of cementless 15 hip arthroplasty. During the insertion, a compromise must be found for the number and energy of 16 impacts that should be sufficiently large to obtain an adapted primary stability of the FS and not too high 17 to decrease fracture risk. The aim of this study is to determine whether a hammer instrumented with a 18 force sensor can be used to monitor the insertion of FS. 19 Cementless FS of different sizes were impacted in four artificial femurs with an instrumented hammer, 20 leading to 72 configurations. The impact number when the surgeon empirically felt that the FS was fully 21 inserted was noted Nsurg. The insertion depth E was assessed using video motion tracking and the impact 22 number Nvid corresponding to the end of the insertion was estimated. For each impact, two indicators 23 noted I and D were determined based on the analysis of the variation of the force as a function of time. 24 The pull-out force F was significantly correlated with the indicator I (R${}^2$ =0.67). The variation of D was 25 analyzed using a threshold to determine an impact number Nd, which is shown to be closely related to 26 Nsurg and Nvid, with an average difference of around 0.2. This approach allows to determine i) the moment 27 when the surgeon should stop the impaction procedure in order to obtain an optimal insertion of the FS 28 and ii) the FS implant primary stability. This study paves the way towards the development of a decision 29 support system to assist the surgeon in hip arthroplasty.
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