Steinberg staging system [23].
\\n\\n
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
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\r\n\tRapid urbanization is one of the most important global change problems that land-use planners are facing worldwide. With increased population growth and urbanization, cities around the world are becoming more affluent and putting even greater pressures on various land uses. The greatest challenges include managing traffic and transportation, the urban sprawl of cities, and affordable housing in ways that can improve people’s health and social well-being in a city-based framework, keeping in mind qualitative principles of equity, public participation, and sustainability. The proposed book hopes to bring together leading scholars in the field of transportation or engineering, land use planning, affordable housing, and smart cities growth, to discuss contemporary land use issues and challenges facing cities in both developed and developing countries. The book is also intended to serve as important reference material for academics, land use planning professionals, and students around the globe seeking to understand contemporary land-use problems and innovative solutions.
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Industry 4.0 combines and connects digital and physical technologies including artificial intelligence, the Internet of Things, additive manufacturing, robotics, cloud computing, and others to drive more flexible, responsive, and interconnected enterprises capable of making more informed decisions [1]. The infusion of digital technologies in the value chain processes of research and development, design, production, marketing, distribution, and customer services will drive efficiency in production, thereby increasing the ambits of international trade.
Developed in Germany, currently, Industry 4.0 has become the most discussed issue in the industrial arena in the world. Both managers and policymakers from developed, emerging, and developing countries are debating this issue about how they can participate in this fourth industrial revolution as well as save them from the fallout of this advancement. The issue is still evolving, and experts from all spheres of industry and markets are debating on it. The objective of this chapter is to participate in this debate and explore how Industry 4.0 will evolve in the coming years and how it might affect international trade and the global value chain. We will take an in-depth look into what exactly is Industry 4.0 in our globalized context, what it brings to the table when it comes to international businesses and how international organizations can benefit from Industry 4.0 in their globalization strategies? As a matter of fact, Industry 4.0 outperforms the previous industrial revolutions we have gone through during the past centuries. The fourth industrial revolution is the result of the combination between the real and the virtual world, in which deep learning encourages and challenges human capacities and frontiers, particularly, with the increase of cyber-physical systems. Indeed, the new industrial revolution which develops deep learning is not limited to the use of automation systems based on machine learning, but autonomous ones that do not systematically depend on human beings and which can learn and act by themselves. Industry 4.0 refers to many concepts such as artificial intelligence, smart technologies, smart factories, smart automation, or smart management like the implementation of enterprise resource planning and automation of robotized processes. The global business environment has already started to enhance efficiency with futuristic and high-value-added technologies, from which we are not able to see the frontier clearly for now.
Firstly, we will undertake a brief literature review to explain how we structured our work. We will then be having a great detailed analysis of Industry 4.0 and its main components and how it is changing the way corporations do business in an increasingly connected world. Parallelly, we will explore the opportunities that the fourth industrial revolution brings as well as the challenges which emerged from this new revolution in order to counterbalance and give a realistic view of the latter. Finally, we will illustrate the major strategies that can enable the organization to avail opportunities emanated from Industry 4.0.
Industry 4.0 contributes to the virtualization of a physical production environment that facilitates connectivity and interaction between the machines as well as man and machines in real-time. The automation and connectivity as well as machine learning facilitate the inter-connectivity and improve the production process and bring several benefits to the organization. Some of them are presented in the following sections.
Industry 4.0 is a generator of efficiency. Indeed, the great use of technologies within the different steps in the supply chain helps with optimizing the latter. It is, therefore, cost-effective, time-effective and it globally enhances productivity as well as flexibility and quality of outputs, which also raises the overall reliability of the firm and so the value of the company and its competitiveness. Industry 4.0 is not only about using high technology machines to produce more rapidly. There is indeed much more to that. Industry 4.0 can contribute to streamlining the value chain thanks to its transformation of every aspect of the production process from the logistics, passing through the managerial issues, to the networks, and more generally, the whole structure of firms in the network.
First of all, firms can benefit from
Data is the basis of all the improvements around artificial intelligence and the comprehension of the opportunities that can be taken in the organizations. Used correctly, data and communication tools can help firms to better respond to customers’ demands and allow a better accuracy of forecasts too. Data within the industry can help to see what should be improved in terms of production methods to gain efficiency. In that sense, they can also more easily identify bottleneck products which would result in better opportunity costs. Firms can also benefit from greater management and control thanks to adapted software within the firm. Data can be used to analyze production time and costs, as well as comparisons of portfolios of suppliers and materials to get the best of their interest. It allows a rapid reaction to changes and errors. It also allows a quick adaptation when it comes to stock levels, wherever it is from the production or the purchasing teams’ perspectives. Finally, data is the base of artificial intelligence. Thanks to machine learning, data is used to learn from mistakes and successes, which is crucial to be exponentially improving.
Thanks to data, programs are elaborated to improve the business networks such as suppliers with industries or with clients, or from clients to employees when they make a requirement for a change in the process of making an order. The communication is smoother, quicker, and easier to take action. Technologies also allow better safety of work conditions. The efficiency of new technologies allows companies to be more sustainable thanks to smart production facilities, which allows a better allocation of resources and vertical networking of smart production systems. The vertical networking of smart production systems can be defined as
The most blatant of the effects of efficiency in this modern revolution is customer satisfaction. Indeed, thanks to the advanced technologies, customers demand is well –
Customization is an important issue in the global manufacturing industry, and its relevance is expected to even increase in the future. Customers want to customize the design of their products and by influencing the development and production processes at an early or even late stage. This tendency creates the need for manufacturing companies to move from the objective of better products for their customers to the objective of an individualized understanding of customer needs and specialized, industry-specific solutions [5]. That is to say, a major shift from an economy of scale to an economy of customization regardless of the location of production sites in the global value chain.
This ongoing change of customers’ needs results in more and more system complexity in system design as well as in assembly. Furthermore, commissioning can only be partially compensated by manufacturers’ standardization and modularization efforts. Nevertheless,
Assembly line production systems will also be affected by an increase in flexibility in production. Bortolini et al. [8] state that products produced in assembly lines will not only be able to be personalized but that late customization (i.e., after the order has been placed) will also be possible because real-time information on the status of the production process will be available. This means that customers will not only be involved in the definition and design of the product and its specifications, as is the case with mass customization products but will also be launched once in a late customization mode [9].
In contrast, mass-customized production facilities typically produce large volumes of products that share a common core but may be customized to a certain degree [9], creating production process sections with repetitive larger lots (e.g., automotive press shop) and sections of high product variance (e.g., final automotive assembly). The customers of mass-customized production factories typically customize their products based on a predefined set of configuration options, which can be integrated into a common modular architecture. Mass-customized production type factories are typical in the automotive industry, automotive Tier-1 suppliers, and, to some extent, in the truck, bus, agricultural, and construction equipment sectors. Industrial equipment manufacturers – where factories simultaneously have large production volumes and accommodate an ever-increasing number of variants – run mass- customized production type factories as well.
Therefore, the strategy of providing differentiated products leads to a paradigm change in manufacturing planning, posing new challenges for industrial activities. To satisfy the new kind of markets, industries had to adopt agile models, exploiting the competitive advantages of each organization [10]. These manufacturing models intend to face the uncertainty of the market by increasing the response capability of the organization in order to satisfy the customers with similar costs to mass-production industries [11]. Handling the production of large amounts of customized products presents a tough challenge since product differentiation hampers scale economies.
However, managing the production of personalized or customized goods will be quite demanding, given their different requirements. Finally, when late customization of the customer is possible to be accepted and when it is not, it depends on the production sequence in execution, and when it is possible to apply to re-sequence to incorporate the late customizations. Moreover, the advantages of late customization processes can be achieved only if the system is autonomous and can keep running the fabrication process. The customer needs real-time information about the evolution of the production of its personalized product [12]. And, as Kietzmann et al. [13] comment in the context of additive manufacturing,
Before Industry 4.0, companies used traditional data sources such as production records, internal accounts, and market research reports with a limited range for their decision-making process. The way of data sourcing is changing. Data is more and more generated from sources like sensor-generated data from smart products and data from search engines and social media sites. This technological shift offers multinational compagnies (MNC) the opportunity to access new worldwide business-relevant information. Additionally, technical progression regarding computing power and data storage costs is taking place. This results in the development of big data analytics [14, 15, 16].
To understand the innovational power of big data analytics, it is important to understand the changed concept about time in comparison to data analytics before Industry 4.0. Big data analytics is looking into the future and tries to generate existing and new data sources. The traditional role of information technology has been more backward-looking and concerned with monitoring processes and notifying management of anomalies. Firms that have adopted big data analytics report improvements in productivity and financial performance. For example, analysis of big data can enable managers to identify defects, faults, and shortcomings in the production process at an early stage, optimize automation processes and carry out trend analyses, use resources more efficiently and carry out predictive maintenance [17].
The potential implications of big data analytics for international business are several. In particular, firms will be able to monitor emerging trends and opportunities in overseas markets without the need to make substantial resource commitments in those local marketing affiliates, and they will be able to optimize more effectively their supply, production, and distribution activities around the world [18]. But there are two major drawbacks. The first is that the availability of good-quality big data may well be a source of value for firms, but successful firms will require a range of technical and governance capabilities to analyze and operationalize that data so as to realize the potential benefits [19, 20]. The second is that individuals’ privacy will be under threat from widespread big data applications. Like Facebook knows what we like, Google knows what we browse, and Twitter knows what is on our mind [21].
New data protection laws and/or stronger industry self-regulation will need to be formulated to safeguard the privacy of individuals and companies, and to put limits on what data can be accessed, stored, and transmitted both nationally and across borders [22]; Rose et al. [23]. It has to be discussed who will have legal title over what, and who will bear legal responsibility for, products that involve consumer-generated intellectual property [24] and how will these issues be handled in cross-border settings? Some form of (transnational) governance regime will be necessary to regulate this dilemma between the benefits of big data analytics described earlier and data privacy. Finally, this may influence or even determine the abilities of firms to maximize the commercial potential of big data analytics [25, 26].
The optimization of production and logistics processes allowed by Industry 4.0 could have a major impact on the management of the environmental crisis. Indeed, the processes of Industry 4.0 that allow energy savings and waste reductions to cut costs for firms would be equally beneficial for the preservation of natural resources and biodiversity. The Sustainable Development Goals established by the United Nations include the improvement of energy efficiency and better management of waste. Therefore, the improvements brought by Industry 4.0 would be in adequation with government environmental policies and regulations, which will most probably become much stricter in the coming decades.
Industry 4.0 allows improved production management thanks to the production monitoring capabilities of Industry 4.0. Constant monitoring of production efficiency and intelligent quality control offer great opportunities in terms of production efficiency, waste reduction, and improved reliability. Consequently, firms would have a better energy efficiency [27]. Industry 4.0 allows firms to make informed decisions based on the data-mining possibilities brought by sensors and AI. Relevant statistics on production efficiency, product life cycle, and energy consumption will be available to the firms [28]. Industry 4.0 will also connect the consumer with its energy consumption thanks to the sharing of statistics made possible by smart data communication technologies [29]. Energy consumers will be informed on their consumption, and this will promote self-responsibilities.
However, these improvements could easily be counterbalanced by the fact that Industry 4.0 requires the collection and storing of massive quantities of data in data centers, which significantly contribute to global warming. But this is not a fatality, and firms should not be stopped by this challenge, as innovative solutions allow the heat produced by data centers to be reused as a heating source. This strategy is especially used in Nordic countries such as Finland or Sweden.
Research on Industry 4.0 is numerous and rapidly evolving. Many types of research have addressed the evolution of the Industry 4.0 (I4.0) phenomenon and its contribution to international business activities. Especially the major drivers of I4.0 that underlines its involvement to enhance current business practices by streamlining both the production and supply chain networks [30, 31]. Those developments in Industry 4.0 have huge implications on the way the current business activities both at home as well as across the globe (i.e., international trade) are being conducted. Mamad [2] has addressed how Industry 4.0 works and has made a broad illustration of the subject in detail through an exhaustive literature review. Deloitte [3] provided an overview of the beneficial application of Industry 4.0 to enhance organizational processes. McKinsey’s [6] study focused on customization and explained how Industry 4.0 has reshaped the manufacturing industry to fit customer demand and how companies can reap profit from these upcoming innovations by showing application opportunities. UNIDO [32] report has presented an impact analysis and showed how Industry 4.0 could contribute to environmental sustainability. Jayashree et al. [33] showed how Industry 4.0 could contribute to developing dynamic capabilities and realizing triple bottom line (TBL) sustainability. Bibby et al. [34] give some tools to assess the current level of Industry 4.0 maturity of businesses that want to transition to I4.0 and better approach the issue. Dhanpat [35] reminds us of the underlying dimensions of I4.0 as a growing need for learning capacities of smart technologies to cope with the new era of cyber-physical systems. Ahmadi et al. [36] addressed the main architecture models of value-chain structure in Industry 4.0.
Industry 4.0 brings both enormous opportunities and challenges for the industry and international trade. It helps not only to modernize the production process and self-initiated execution but also allow the managers to undertake the management of the production process across the globe by creating a flexible global supply chain.
The fourth industrialization is changing the way we perform different kinds of business activities by drawing its main components and their contribution to the business environment. Industry 4.0 is the implementation of cyber-physical systems for creating smart factories by using the IoT, big data, cloud computing, artificial intelligence (AI), and communication technologies for information communication in real-time between the man-machine and machine to machine communication which is redefining the global value chain.
According to Horvàth et al. [37], there are five key drivers of Industry 4.0: Digitalization, optimization, and customization of the production, automation, and adaptation, human and machines interactions, and collaborations, high value-added offers, and automatic exchanges of data and communication. The fourth industrialization has contributed to critical transformation to the international business environment in the different stages of an organization such as human resources, financial systems, management, organizational structure, or production processes.
Those key drivers are highly illustrated by the implementation of cyber-physical systems, the internet of things, smart factories, smart technologies, cloud computing, and big data. The latest architecture of industrialization pursues new objectives and faces completely different challenges that increase in a global perspective. Industry 4.0 offers an opportunity of restructuring declining manufacturing industry in the high-cost-country (HCC) and permit to maintain a strong industrial base in developed countries [38]. It could represent a great opportunity in the context of declining manufacturing in the developed markets. Industry 4.0 answers three key challenges: better competitiveness, flexibility, and agility by facing global offer end demand fluctuation and the regionalization of production [38]. To sum up, Industry 4.0 can be understood as multiple solutions built to change the international industrial sector to gain stronger competitive positions, market shares, especially within a risky business environment. This ambition should be realized by using smart technologies and factories that ensure efficient response to the variation of the global market by improving competitiveness and agile management, which will conduct the changes implied by Industry 4.0.
Central to the fourth industrial revolution is an interconnected network. The internet enables many small firms to participate in global trade, thus, leading to more inclusion. It makes it possible for more products to be exported to more markets, often by newer and younger firms. A 10-percent increase in internet use in the exporting country is found to increase the number of products traded between two countries by 0.4 percent. A similar increase in internet use of a country pair increases the average bilateral trade value per product by 0.6 percent [39]. The transformation implied by the fourth industrialization, Industry 4.0, might lead to significant changes in existing business models allowing new ways to create value. These changes are expected to result in the transformation of traditional value chains. Industry 4.0 affects three elements of manufacturing small and medium enterprises (SMEs): value creation, value capture, and value offer [37].
The 4th industrialization will completely change global value chains by transforming its practices and objectives. The purpose is not limited to monetary rewards but includes new trends such as the willingness to gain efficiency, to create and sustain global competitive advantages, finding new ways of producing, generating innovations, stimulating automation and learning, or even increasing customer implications in the production processes.
Several opportunities generated by Industry 4.0 are transforming the current business levels and activities through its drivers. Multiple business models are flourishing in the Industry 4.0 era. One of the fast-emerging models of them is the
Internet of things (IoT) is retained as a pillar of I4.0. This type of technology provides access to the internet by using deep learning technologies. This equipment transforms machines into smart objects that could, for instance, detect wear, control the performance of the production process, plan the capacity or even manage stocks in real-time. Cloud computing allows interconnection between computers and the internet. It can solve many issues such as Big Data storage as well as the costs and capacities linked to this storage.
Cyber-physical systems (CPS) are mechanisms that allow Humans, software, and machines to interact. It implies an aggregate level of networking. The main purposes of this technique are, by creating such virtual interconnection, to exchange key information to make better strategic decisions. It establishes strong links between production processes, machines, and the virtual world, which work and communicate thanks to computation and the internet in real-time cooperatively. The machines and physical systems will be synchronized to software, and it will allow the control and assessment in real-time production efficiency, adjusting it and making the right strategic decisions easily. Also, CPS enhances the integration of autonomous machines and the collaboration between humans and cyber work.
The result of the use of the different drivers (IoT, CPS, Internet of Service, ERP) will lead to the creation of smart factories, which brings all the smart tools and models together in its production model. This integrated system will facilitate the globalization of production and expansion of global supply chain. It is true that some of manufacturing activities might be re-shored but at the same time, the new smart technology will allow firms to reconfigure their production network overlooking the national boundaries and distance. That is the reason why it is still in the pre-paradigmatic stage of Industry 4.0. implications it is a continuous process that conducts the transformation of our current or traditional methodologies to do business and conceive industrial purposes and processes. As a result, the production model of smart factories becomes cost-effective and flexible to market changes and sustainable, which would reflect the highest level of effectiveness feasible to achieve. This newfound technological prowess will modify drivers of global production networks (GPN), reduce the importance of physical distance as well as re-configure the global value chain (GVC). The new global division of labor (NGDL) is likely to emerge and re-distribute the manufacturing activities integrating different hubs from both the developed, emerging, and developing markets.
There are no doubts about the enormous challenges that Industry 4.0 will bring to the current practice of production, consumption, and global value chain (GVC). Firms and policymakers need to take into consideration adequate strategies to better implement the Industry 4.0 systems, re-organize business activities by taking into consideration of new context and take other caution for the long-term growth of the fourth industrial revolution and reap profit from it. We will define and analyze in this section the challenges raised by Industry 4.0, starting with implementation challenges, then the challenges surrounding the management of Human resources, then the risks to data security, then the Big Data challenges, and finally, the challenges concerning the environment.
As we established earlier, the transition to Industry 4.0 brings countless opportunities for businesses to increase their efficiency and development. However, there are many barriers to the implementation of Industry 4.0, the most important lackings are the shortages of skill-sets that are required in the Industry 4.0 phenomenon. There is also a lack of experience and hindsight on the transition, the necessity to remodel the entire organization, and the coordination of data resources. Added to these challenges are the inequality between SMEs and MNCs in terms of resources, focus, and strategies in the transition to Industry 4.0. This section will present the three main difficulties faced by firms integrating Industry 4.0.
The lack of experience is certainly one of the biggest factors that hold back the businesses from transitioning to Industry 4.0. era. Indeed, the transformation of the companies is very costly, and no clear business case is available as a reference for companies. It is very difficult to justify such investments when there is no perspective, no pattern to follow, and no successful case to reproduce. Therefore, most frequently, companies will either fail in their transition (60% rate of failure) or simply lack the necessary courage to follow through the process of radically changing their organization and investing as much time and resources.
To tackle this challenge effectively, some interesting research in the field has started to emerge, building the first tools to approach the transition. According to Bibby et al. [34], firms should begin by assessing the current level of Industry 4.0 maturity in their specific context or supply network. This analysis will help them determine their strengths and weaknesses and focus their improvement on the right area. Few academic research has been done so far in this area, and many research are done by consulting firms. As an example, in order to assess the industry maturity level of firms, two Industry 4.0 assessment models have been developed in 2016 by consulting firms, IMPULS management consulting GmbH (IMPULS) and PWC. While the PWC model helps companies self-assess their level of maturity based on various criteria, the IMPULS model is focused on delivering improvement advice based on the company’s preparation. More of these models are currently developing, showing that the challenge of the lack of experience will likely be overcome with time as Industry 4.0 spreads across the manufacturing world.
The transition to Industry 4.0 from a traditional organization requires the restructuring of the entire organization, as tasks are automated and decision-making processes are programmed. Every firm that will adopt Industry 4.0 system. We will have to create new business models and define a new strategy. Indeed, this transition requires rethinking the whole organization and processes, interconnecting departments, buying new equipment or modernizing the existing one, re-assigning roles to employees, recruiting new operators, and many other disruptions of their current model. These major changes have a great cost for any business on many levels: financially, of course, but also in terms of time. Therefore, firms have to be especially careful when investing in these transitions in order to not fail its implementation of Industry 4.0.
Another challenge of the implementation of Industry 4.0 is how to connect all data efficiently. Industry 4.0 requires the cooperation of all organizational units, from manufacturing, R&D, IT, to sales and finance departments. Sometimes the walls separating these departments are very hard to break, adding to the difficulty of the transition. But the coordination of functions is only part of the issue: Industry 4.0 requires the management of the large quantities of data generated by diverse sources in the company. For example, production data will have to be processed and coordinated along with data from customer information systems. Data Integration is, therefore, a very difficult task, and the firms need to have the necessary talent from data scientists that will be able to process and model this data.
More than 98% of firms in the developed markets are considered as SMEs, and they are increasingly participating in the global value chains and global trades of goods, services, and components. Introducing the new I4.0 paradigm may have varying levels of difficulty depending on the size and available resources of the targeted firms. Starting conditions between Small and Medium Enterprises (SMEs) and larger firms are obviously very different and bring different challenges. According to Matt et al. [43], SMEs need specific strategies to properly implement I4.0 to their business model.
Large companies will usually follow the higher maturity level in the technological domain faster and more easily than SMEs because of the resources. Indeed, they have more money, expertise, and time to invest in this project. As a consequence, I4.0 is spreading more quickly across large companies which are investing and working intensively on introducing and enabling the necessary technologies. SMEs, however, are lagging behind because they lack the financial and human resources to research into the risks and potential of implementing I4.0. These difficulties further enlarge the gap between SMEs and large multinational companies. However, SMEs have an advantage over large companies, which have a much more complex organizational structure and production processes. Therefore, it is much easier to implement the necessary changes to the organization and culture of SMEs.
According to the study made by Glass et al. [44], across 176 SMEs and 71 large enterprises, numerous barriers to Industry 4.0 must be underlined across business processes and models. The most important challenges include, of course, the multiple issues which arise from Industry 4.0 strategy modeling and the growing need for highly skilled workers with specific know-how, particularly oriented in high technologies, smart engineering, automation, and digitalization competencies and expertise, etc.
We can easily understand that, beyond such technical and future-oriented subjects applying to industries, which is already developed in multiple kinds of business corporations, human resources remain a major challenge for the spread of Industry 4.0 concepts, methodologies, models, and tools. For instance, Mubarak and Petraite [45] have raised a fundamental HR component of Industry 4.0 implementation: The concept of digital trust. Digital trust is situated between trust and Industry 4.0 implementation and implies HR issues. We can identify major human resources issues related to Industry 4.0 as the followings:
When digital trust refers to a new working environment where technology and Humans interact for the welfare of a company and to answer the stakeholder’s needs, a danger of this approach would be the growth of technocentric businesses. In fact, in this model, the stakeholders will give more confidence to technologies, artificial intelligence, and automation to run their business activities and corporations rather than human beings. Indeed, The Deloitte reports questioned the preparedness of HR in an era of Industry 4.0 and the global value chain. Among the 32% of firms that are ready to face technological challenges, only 12% are ready to face the challenges emanating from the Industry 4.0 ecosystem [46]. This statistic illustrates the new trends for companies to focus on efficiency with the highest technological implementation rather than hiring people and maintaining their position through retention policies.
The information systems of human resources (ISHR) illustrate the Industry 4.0 impact upon Human resource function. Indeed, the ISHR technologies permit to automate, standardize with the intervention of smart technologies, activities that belong to HR functions as the following ones: Administrative procedures, training, payrolls management, recruitments, talents management, or even career development of employees within a company [47, 48]. The different systems like automation of robotic processes (ARP) and enterprise resource planning (ERP) were conduct to rethink the HR function. Those different tendencies push HR workers to acquire new competencies geared towards smart technologies and which are transforming their workstation, and which are implying news risks. On the one hand, we can identify the complexity of adaptation to the rapid change of HR function but also the risks linked to the security of information systems and the possibility to lose sensitive data to the benefit of the competition. As a reminder, ISHR systems such as the one proposed by the SAP software can contain confidential data such as the wages, the positions, the personal data of each employee, their curriculum vitae, the annual reports, information posted on the different job board and the main partners of the company, etc.
The fourth revolution required a highly-skilled workforce to be implemented, developed, used and maintained. As a result, a wide range of industries needs a certain level of cooperation between machines and workers. If Industry 4.0 implies this tendency, it also underlines the growing trend of Google, Apple, Facebook, Amazon, Microsoft (GAFAM) to conquer traditional industries in which they have the necessary knowledge and capacities to become undisputable competitors in multiple fields [49]. As an example, we can remember the creation of the Google autonomous car, the collaboration between the Volkswagen group with Amazon web services to collect and analyze its industrial data and becoming a major global leader of the automotive industry, and even the collaboration between Apple and General Electric (GE) to create new applications for the internet of things (IoT) platforms that benefit to GE industries purposes thanks to IOS (exploitation system owned by Apple) opportunities. Industry 4.0 increases competition, in traditional industries and markets (but not only), which seems to be overwhelmed regarding the fast spread of the fourth industrial revolution. To overcome these challenges, companies must recruit high skilled workers, implementing continuous reskilling, learning, and training programs in their HR policies [44]. Besides, one of the major HR issues is constituted by the launch of retention practices which will reduce the diffusion of confidential business information and enhance efficiency and profitability by staying competitive at the same time. We can understand that the rise of high skilled workers’ demand would create a danger if it is not associated with HR policies to enhance workforce abilities to work in a new smart and autonomous workplace.
One major issue to face urgently for HR function is the resistance to change. According to Deloitte [50] report, 17% of their interviewees are ready to manage working environments composed of people, robots, and AI interacting together when 60–70% will fail because they do not manage the adaptation to change properly. Also, Dhanpat et al. [35] confirmed this problem. They have shown that some employees can be resistant to change by being afraid of losing their jobs and being replaced by machines. Bonekamp et al. [51] also agree on the fact that the introduction of Industry 4.0 led to the suppression of standardized tasks by smart and autonomous systems. As a consequence, strong pressure is put on HR managers who require highly skilled people, to train employees and manage to dismiss workers for whom their tasks will be replaced by smart technologies to gain efficiency and competitiveness in the global market. In 2016, The World Economic Forum (WEF) already raised awareness by making an announcement before the opening of the Davos forum: around 5 million jobs in 5 years will be suppressed within 5 years in the main global economies [52]. It is necessary for the HR function globally to answer and react to the exponential expectations of the fourth industrial revolution by taking into account its effect on the global workforce demand and its impact on the global economy and competitiveness.
The fourth industrialization reveals new challenges in business activities such as the management of Bigdata and cybersecurity. Multiple obstacles to Industry 4.0 remain redundant: The constraints are numerous because the digitization of the industry poses formidable problems of standardization and cybersecurity [52].
Indeed, through their researches, one of the major challenges implied by this concept in the working environment is the deployment of Big Data, which creates a growing need to provide a legal framework for the protection of personal data and private life. Among the different cyber issues reported in Industry 4.0, the Deloitte report [50] identifies the top 10 cyber threats and their major data protection concerns.
Indeed, if legal restrictions increase to manage big data challenges, the different issues persist. In terms of an international legal framework, the ISO norm ISO/IEC 27001 defines the data security management for sensitive subjects such as financial, intellectual proprietary, employees, or even data entrusted to another company in the context of business activities. This norm is also called “Management systems of Information security” [53]. In addition, the European Union has implemented the General Data Protection Regulation (GDPR) to mitigate different kinds of challenges affiliated with the management of Big Data. GDPR regulations refer to “imposing a legal framework on the processing of personal data” [54].
However, despite the willingness to build an international legal framework to reduce risk related to Big data cybersecurity, there are still a long-ways to go for a proper framework of Industry 4.0. For instance, Deloitte report has shown that one out of four firms is not developing, implementing, or documenting the industrial cybersecurity (ICS) specific policies and procedures, and more than 33% of manufacturers have not performed any cyber risk assessments specifically focused on the ICS operating on their shop floors, resulting in a potentially significant risk to their operations [55].
In terms of internal management, other issues can arise when a company starts using big data analytics in order to grow. The challenges to take into account include the lack of proper understanding of big data, and therefore, proper usage of the latter; data growth issues, or, “what do I do with this much information?” because the collection of such an amount of data must be useful for something. But what, exactly? Another issue is the confusion when selecting a Big Data tool. There is an increasing number of tools available on the market for firms to have reports and data concerning their businesses. However, it is often not very precise and easy when one is not really aware of what is best for them. This last point brings us to another issue which is the lack of professional expertise in the field of Big Data. Indeed, more and more companies are recruiting professionals and experts in the field of data, such as data scientists, engineers, and analysts. These professions are rare, and as the demand and supply rule confirms, it is quite costly for a firm to recruit, though it is a must when expecting to grow, especially in our current globalized market.
Concerning the international strategies of Industry 4.0 applied to firms, we can find key references in terms of Smart Manufacturing architectures: Reference Architecture Model or Industry 4.0 (RAMI 4.0), Smart manufacturing ecosystem (SME), Intelligent manufacturing system architecture (IMSA). In Smart manufacturing, the architecture corresponds to the designing of the arrangement and connectivity of the organizational structure. The Smart manufacturing ecosystem (SME) provides a standard overview of Smart Manufacturing Systems (SMS). It has three dimensions: product, production, and business. It allows information circulation, in order to follow the production of products through its entire life-cycle. It focuses on the entire value chain and the interaction between the three dimensions.
According to a BGC report on Industry 4.0, related to the German manufacturing industry, Industry 4.0 will be used by an increasing number of firms and generate significant productivity gains of this industry sector (90 to 150 billion EUR). The productivity will improve by 15 to 25%. If material costs are considered, productivity upgrades of 5 to 8% are realistic. Individual effect size depends on the specific manufacturing industry. E.g. industrial component manufacturers will see the largest productivity gains (20 to 30%), while automotive manufacturers may assume 10 to 20% [56]. Furthermore, Industry 4.0 will impact the revenue growth of the German industry. Need from manufacturers for improved devices and new data applications, as well as customer demand for a greater range of increasingly customized products, will provide further revenue growth of around 30 billion euros per year, equivalent to around 1% of German GDP.
The BCG study predicts that the growth and productivity increase described above will also positively impact the employment growth of 6% over the next decade. The need for mechanical engineering workers could increase even more – by up to 10 percent over the same period. In the next few years, the automation trend will replace some low-skilled workers in repetitive and monotonous tasks. However, the increasing use of big data analytics will increase the demand for workers with ICT skills. This shift of needed skills transformation is one of the most important challenges of future growth and innovation. Making the mandatory steps to be economically successful in the world of Industry 4.0 will cost manufacturers about 1 to 1.5 percent of their sales in absolute value over the next decade. Finally, it can be concluded that Industry 4.0 will transform the global value chain, labor market, and logistics.
Global trades are going through lots of volatility from geopolitical instability and natural disasters. The current situation requires businesses to develop their strategic goals for growth, risk management, and global supply chain for the short term, mid-term as well as long term. Manufacturing firms need to develop multi-pronged and multi-disciplinary approaches to address challenges facing current and future supply chain disruptions. The use of advanced technologies like artificial intelligence (AI) and Business analytics can be helpful to analyze large-scale data and keep track of supply chain movements in real-time and develop the ability to re-configure the Supply chain on short notice. A firm’s ability to succeed in global markets will depend on the capacity of the industry to adapt to a rapidly changing business landscape.
To sum up, Industry 4.0 seems to have reached heights when it comes to the organization of enterprises at a global level. We described how international organizations could benefit from Industry 4.0 doing international business. We explained how the components of Industry 4.0 had enhanced many aspects of SMEs and MNCs, by analyzing the evolution of the different phases of the historical context to come to such a strong, advanced stage. We, therefore, defined the industry and its key components to explain its contribution to the organization.
Managers need to develop the ability to identify the opportunities and the strengths brought up by this industrial revolution. We took a look into its efficiency features, and opportunities to satisfy the varied demands thanks to capabilities of customization, and the power of the use of Big Data Analytics, as well as the great impact that this evolution has on the environment. Nevertheless, all these benefits do not come without some challenges. Indeed, Industry 4.0 has full of potentialities of innovation and quite complex transformations to simplify and adapt organizations, especially in terms of human resources because robotics and automation will have huge a repercussion on the social aspect. Most especially, developing and emerging countries that participate in the global value chain by offering advantageous manufacturing production locations will face stiff competition between Industry 4.0 based technologies with those of cheap and abundant labor force in those countries. There is no option other than up-grading the workforce and integrating into the 4.0 era to face these new challenges in the era of Industry 4.0. Finally, as valuable as Big Data can be for the industry, we have found out that it is still a domain that requires particular attention since its use remains quite laborious.
Nonetheless, this modern revolutionary phase is not the last of its category. In fact, the very recent rise of Industry 5.0, a solution provider for people and the planet has flipped the script. Indeed, the new revolution of Industry 5.0 puts an emphasis on the well-being of the workers and captures all the added-value components of Industry 4.0 with the aim of prosperity in the new industry as an ambition for a better future.
The presence of a heterozygous glutamic acid to valine substitution on chromosome 11 in the β-globin gene is known as sickle cell trait, which is found in around 300 million individuals across the globe [1]. In comparison to the homozygous genotype (HbSS) in individuals who have sickle cell disease, individuals with sickle cell trait possess heterozygous genotype (HbAS).
Over the years, few bone complications have been reported in sickle cell trait that is back in the 1970s era [2]. It is pretty uncommon that people with sickle cell trait suffer from a vascular necrosis (AVN) of bone and femoral head as the most common destruction site [3].
Multifactorial etiology is investigated for nontraumatic a vascular necrosis of the femoral head. In the majority of the cases (30–70%), both the hips are affected by the lesion [4]. The cause of AVN of the head of the femur is yet unknown. However, several risk factors have been linked to the development of this disease.
Sickle cell anemia, alcohol consumption/abuse, hemoglobinopathies, myeloproliferative disorders, chemotherapy, pregnancy, genetic susceptibility are chronic steroid usage, smoking, coagulopathies, leukemia, ionizing irradiation, and HIV infection are considered as the main risk factors [4]. The fundamental pathophysiologic cause of osteonecrosis in sickle cell disease is the obstruction of micro vessels, resulting in ischemia and oxygen and nutrition deprivation of the afflicted bone [5].
Sickle cell disease is the most common cause of osteonecrosis in children, with a prevalence incidence of 3% before 15 years. Sickle cell trait is thought to be primarily protective, particularly in the case of malaria. Despite this therapeutic benefit, afflicted carriers might have various problems and clinical sequelae, including exercise-related injury, venous thromboembolism, and renal difficulties [1, 6].
The possibility of AVN of the femoral head in sickle cell trait was reported by Perumal and Corbett [7]; however, there is a need for additional research. This index case describes and raises awareness of a vascular necrosis of the femoral head and its relationship to sickle cell trait.
The autosomal recessive genetic disorder sickle cell disease is marked by abnormal sickle hemoglobin synthesis and reduced pliability of red blood cells. It causes blood arteries to clog, resulting in ischemia and infarction of the afflicted tissue [8]. Despite being indigenous to tropical Africa and the Middle East, it has become a worldwide disease due to population movement [9].
One of the most prevalent sickle cell disease clinical signs is bone involvement, which can vary from an acute severe vaso-occlusive crisis to a persistent impairment such as a vascular necrosis. Pathological fractures, septic arthritis, osteonecrosis, and osteomyelitis are orthopedic consequences of sickle cell disease [10].
The most common location for a vascular necrosis in sickle cell disease is the femoral head, followed by the shoulder, knee, and other minor joints [11]. A vascular necrosis of the femoral head causes hip osteoarthritis and reduces its functional capability. To avoid morbidity and mortality associated with late diagnosis, osteonecrosis must be diagnosed early and treated promptly. The majority of orthopedic surgeons advocate complete hip replacement to increase functional capacity [12].
In sickle cell disease patients, aberrant metaphyseal femoral morphology with thin cortices and trabeculae, low bone density, and medullary hyperplasia are only a few skeletal abnormalities that affect the hip joint. The femoral canal can also be obliterated by irregular bone sclerotic regions, resulting in hip joint congruency loss. Thinned femoral cortical lining inside the outer cortex might sometimes seem like a femur inside a femur [13].
The disturbance in the proximal femur’s blood supply causes a vascular necrosis of the femoral head, known as osteonecrosis. Each year, between 10,000 and 20,000 new cases are recorded in the United States alone [14]. It can be caused by a multitude of factors, both traumatic and nontraumatic. Fractures, dislocations, chronic steroid usage, prolonged alcohol use, coagulopathy, and congenital reasons are only a few of the causes.
A vascular necrosis of the femoral head is a devastating illness requiring healthcare providers to look for its symptoms. This exercise will provide you with a summary of the etiology and treatment options, as well as some clinical pearls.
The lateral and medial circumflex branches of the profunda femoris, which is a branch of the femoral artery, give the bulk of the blood flow to the head of the femur. It is known that the profunda femoris is the deep penetrating branch present in the upper thigh region. A ring around the femur’s neck is created by joining medial and lateral circumflex femoral arteries. This is the place from which many tiny arteries branch for perfusing the femoral head.
The foveal artery, also known as the ligamentum teres artery, is another direct route of blood flow. The femur head is linked to the acetabulum through the ligamentum teres. The foveal artery flows through the ligament, but its contribution is only noticeable in children [15].
Two significant anastomoses provide collateral blood flow for supporting femoral; although, the flow is limited;
Cruciate anastomosis—it maintains flow between medial circumflex femoral and inferior gluteal artery.
trochanteric anastomosis—it maintains flow between medial/lateral circumflex femoral and superior gluteal artery.
The internal iliac artery, also known as the hypogastric artery, is the major artery of the pelvis and nourishes a portion of the buttock and posterior thigh [15]. The common iliac artery is derived from the aorta, and the internal iliac artery is derived from it.
The socket of the hip, the acetabulum, is the place where the femoral head is connected. The acetabular branch of the obturator artery provides blood supply to the acetabulum, along with the deep branches of the superior gluteal artery and pubic branches of the obturator artery. Disruption of the blood flow to the head of the femur might produce ischemia and necrosis due to restricted collateral circulation. The osteocytes will die, the articular surface will crumble, and degenerative arthritis will develop if the blood supply is not restored quickly [16].
The etiology of AVN of the femur head is not well established. But several conditions have been regarded as risk factors for its development.
The dislocation and fracture involving femoral neck fracture and the acetabulum are among the most common traumatic causes. A vascular necrosis can result during sorts due to damage of the blood supply to the head of the femur, which is easily disturbed in some traumas associated with sport activities. In total, 15–50% of femur neck fractures and 10–25% of hip dislocations are caused by osteonecrosis [17].
Most nontraumatic etiologies are represented through increased alcohol use and chronic use of steroids, accounting for >80% of the cases. After trauma, the second most common cause of osteonecrosis is steroid-associated osteonecrosis. The actual pathogenesis is unknown and most likely complex despite indications of an association between steroids and osteonecrosis. Fat emboli, fat cell hypertrophy leading to increased endothelial dysfunction, bone marrow stem cell pool abnormalities, intraosseous pressure, and hyperlipidemia are all possible contributors to ischemia and necrosis [18].
There is a lack of understanding about alcohol-induced osteonecrosis. However, proliferation, bone marrow fat cell hypertrophy, blood vessel occlusion, subsequent lack of perfusion, changes in serum lipid levels, and increased intraosseous pressure are known to cause osteonecrosis [19].
Osteonecrosis is frequently triggered by sickle cell disease. Ischemia and bone infarction result from the malformed inflexible red blood cells, with the femoral head being the most prevalent location of osteonecrosis in these patients [20]. Autoimmune and chronic inflammatory illnesses, such as systemic lupus erythematosus, have long been linked to femoral head osteonecrosis. Long-term steroid therapy is frequently related to developing the illness in these people, while there have been instances among steroid naïve.
Perthes, which affects the pediatric population due to idiopathic a vascular necrosis of the femoral head. There is an increased risk of osteoarthritis and losing range of motion due to lack of blood supply resulting in necrosis of the femoral head leading to deformity. The progression of disease takes place in four steps as follows [21];
Necrosis—it is when necrosis begins due to disruption of blood supply.
Fragmentation—resorption of necrotic bone takes place that is replaced with woven bone, with increased susceptibility of either collapsing or breaking.
Re-ossification—development of stronger bone.
Bone remodeling—completion of bone regrowth and finalized shape, considering the damage caused during the second phase of fragmentation.
The development of femoral head osteonecrosis has also been linked to vascular disease caused by diabetes and direct injury by cytotoxic chemicals [22].
A vascular necrosis of the femoral head is expected to develop at a rate of 20,000–30,000 new cases each year in the United States, accounting for 10% of the approximately 250,000 total hip arthroplasties performed each year [23]. This number is comparable to the 0.01% incidence observed in German-speaking nations and the 1.9 per 100,000 incidences reported in Japan.
There is no link between race and sickness, except in cases of sickle cell disease, which is more common among people of African heritage. Overall, men are more likely than women to have this illness, with studies predicting ratios ranging from 3 to 5 to 1 [24]. The average age of the patients at the time of therapy is between 33 and 38 years old [14].
The actual pathophysiologic processes behind a vascular necrosis of the femoral head are not always evident, and the condition is commonly thought to be complex [4]. The consequence is the death of osteocytes and bone marrow due to inadequate blood supply to the subchondral bone of the proximal femur, regardless of the causative event [17]. If not treated adequately in the early stages, this cell loss will collapse the femoral head and subsequent osteoarthritis. It is also clear in literature that the AVN is inevitable end result in some conditions.
Early on in the illness phase, patients may be asymptomatic. However, when they become symptomatic, the most common complaint is hip discomfort that might extend to the groin and thigh. Activities such as climbing stairs and walking worsen the discomfort, which is relieved by relaxation. Even when there is no movement, the pain will often persist [4]. Restricted range of motion, soreness on palpation, and discomfort during abduction and internal rotation of the hip area are some physical exam findings suggestive of femoral head osteonecrosis.
Total hip replacement is one of the most satisfying procedures and has been dubbed the “century surgery” due to its nearly 50-year track record of success [25]. Total hip replacement became popular in the 1960s to restore hip function and, as a result, everyday activities. Since then, surgical technique and surgeon training advancements have led to today’s condition of high-quality prosthetic implants, well-proven surgical indications and contraindications, and evidence-based pre- and postoperative treatment.
On average, 85–95% of hip replacement patients survive [26]. Total hip replacement for sickle anemia is a complicated treatment with medical, intraoperative, and postoperative problems. The success necessary to medically optimize patients and improvements in surgical procedures and prosthetic implant manufacturing has yielded equivalent outcomes for sickle cell anemia patients.
Adherence to proper perioperative measures such as hydration, body temperature management, oxygenation, and a hemoglobin level of over 10 mg/dl contributes favorably to the outcome and is relatively simple to implement. Intraoperative complications such as soft tissue contractures, bone fractures, and perforations are challenging to manage and are a primary cause of poor results [27].
There is a need for further improvement for a hip replacement among the affected individuals, considering the impact of bony involvement such as scoliosis or soft tissue conditions. One such condition is Periarticular Contracture on hip replacement such as degenerative hip and spine for sickle cell anemia elderly patients.
Early detection can have a significant impact on the result. The clinical presentation is combined with adequate imaging to make a diagnosis. X-rays, radionuclide bone scanning, and magnetic resonance imaging (MRI) are all examples of imaging. Imaging in the context of a patient’s symptoms can aid in determining the best course of treatment.
Usually, the plain-film radiography is performed in two planes, using both frog-leg lateral and anterior–posterior films. Subchondral radiolucency, often known as the “crescent sign,” is a pathognomonic indication of subchondral collapse. The “donut sign,” which is a ring of enhanced uptake around a chilly core, might appear when Technetium-99 m is absorbed. At the demarcation, where reactive bone meets dead bone, this indication signifies increased bone turnover [23].
The gold standard for diagnosing osteonecrosis is an MRI. X-rays and radionuclide scans can also help diagnose, but none is as sensitive or accurate as MRI to detect radiographic evidence early in disease development. When determining a patient’s prognosis and devising a treatment plan, MRI can identify bone marrow alterations, the size/location of the necrotic region, the influence on acetabular cartilage, the depth of collapse, and so on [4].
The amount of necrosis can be classified if appropriate imaging has been obtained. While there are other staging systems available, the Steinberg staging system is the most often utilized. It specifies the seven stages illustrated in Table 1.
Stage | Features |
---|---|
0 | Normal radiograph, bone scan, and MRI |
I | Normal radiograph, abnormal bone scan, and or magnetic resonance imaging IA Mild (involves less than 15% of the femoral head). IB Moderate (involves 15–30% of the femoral head) IC Severe (affects over 30% of the femoral head) |
II | Cystic and sclerotic change of the femoral head IIA Mild (involves less than 15% of the femoral head) IIB Moderate (affects 15–30% of the femoral head) IIC Severe (affects more than 30% of the femoral head) |
III | Subchondral collapse (crescent sign) without flattening of the femoral head IIIA Mild (involves under 15% of the femoral head) IIIB Moderate (affects 15–30% of the femoral head) IIIC Severe (affects over 30% of the femoral head) |
IV | Flattening of the femoral head/femoral head collapse IVA Mild (involves under 15% of the femoral head) IVB Moderate (involves 15–30% of the femoral head) IVC Severe (affects more significant than 30% of the femoral head) |
V | Joint space narrowing and acetabular changes VA Mild VB Moderate VC Severe |
VI | Advanced degenerative joint disease |
Steinberg staging system [23].
In patients with suspected osteonecrosis, a laboratory workup should be performed to help rule out alternative causes of hip pain and check for concomitant conditions. The lipid panel, C-reactive protein (CRP), anti-nuclear antibody (ANA), hemoglobin electrophoresis, a complete blood count (CBC), erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (anti-CCP) are some of the tests that may be used in a workup.
Elevated ANA and RF are nonspecific indicators of active autoimmune disease. Inflammatory processes raise both ESR and CRP. However, they are nonspecific. Rheumatoid arthritis is associated with elevated anti-CCP antibodies, whereas sickle cell disease is associated with HbS and a low quantity of HbF on hemoglobin electrophoresis [28].
A CBC with indications of normocytic or microcytic anemia and a high reticulocyte count is also constant with a sickle cell disease diagnosis. Sickle cell disease and rheumatoid arthritis are two disorders that can lead to femoral head osteonecrosis and produce hip discomfort even if there is no osteonecrosis.
A biopsy is rarely required because the diagnosis can frequently be determined precisely based on imaging and clinical presentation. If a biopsy is taken, the typical histological results will be trabecular necrosis (more than 50% empty osteocytic lacunae) and necrotic hematopoietic marrow, with no signs of inflammation, tumor cells, or sepsis [29]. Similarly, angiography tests are rarely regularly conducted, despite their excellent vasculature imaging, and may aid in disease pathology research [28, 30].
A vascular necrosis of the femoral head can be treated in different ways, such as they can be treated through conservative to invasive methods. The particular therapy used is determined on the basis of the patient’s condition individually along with a variety of circumstances for optimal results. All considered are the patient’s age, location and extent of necrosis, comorbidities, amount of pain/discomfort, and whether the articular surface has collapsed. Treatments, which include both operational and non-operative approaches, are best applied during the pre-collapse period. Femoral head necrosis, if left untreated, can develop subchondral fractures in as little as 2–3 years [31].
Treatment options should be depending on the severity of the lesions, but primarily on whether or not they have collapsed. In asymptomatic and symptomatic small to medium-sized pre-collapse lesions, non-operative therapies or core decompression can be beneficial. Bone grafts (non-vascularized or vascularized) or osteotomies can be used to treat medium-to-large lesions. Arthroplasty is recommended if there is femoral collapse or acetabular involvement.
The term “conservative management” refers to a group of non-operative therapies. Physical therapy, reduced weight-bearing, alcohol abstinence, steroid discontinuance, pain management medication, and focused pharmacologic treatment are only a few examples. Because the time it takes for a vascular necrosis of the femoral head to develop and collapse varies widely, and data are poor, there is no consensus on conservative therapies. Despite the fact that minor asymptomatic lesions can heal independently, the majority develop and require treatment.
Off-label usage of statins, anticoagulants, vasodilators, and bisphosphonates has been attempted to revascularize the femoral head. Vasodilators, such as iloprost (PGI2), work by lowering intraosseous pressure and increasing blood flow [32]. Statins inhibit the development of stem cells into fat cells, lowering intraosseous pressure and improving perfusion [33]. Anticoagulants such as enoxaparin are used to prevent osteonecrosis from progressing due to thromboembolic events and hypercoagulability [34]. Bisphosphonates, such as alendronate, block osteoclasts’ ability to reduce bone resorption [35].
There is still no significant consensus on the efficacy of any of these drugs over another, despite the availability of a multitude of pharmacologic treatment options. In general, intra-articular steroid injections are not advised. The benefits of steroid injections are generally fleeting, and their usage might exacerbate a vascular necrosis; although, they can give pain relief.
For individuals who require more intrusive therapy, there are many surgical choices. They are classified as either joint preservation techniques or joint reconstruction procedures. Bone grafts, osteotomy, core decompression, biologics, and cellular treatments are examples of joint preservation operations, whereas joint replacement is an example of reconstructive interventions.
The lateral approach was used for all surgeries. The incision was made around 8 cm down the line of the femur, 5 cm proximal to the tip of the greater trochanter longitudinal incision centered over, the greater trochanter’s tip. The fascia lata was split and retracted anteriorly during the superficial dissection, exposing the gluteus medius tendon.
The gluteus medius fibers that were connected to the fascia lata were removed using sharp dissection. Deep dissection separated the gluteus medius fibers longitudinally, commencing in the center of the greater trochanter and extending the incision inferiorly via the vastus lateralis fibers to avoid harm to the superior gluteal nerve [10]. The anterior greater trochanter and its underlying gluteus minimus formed an anterior flap in the anterior gluteus medius.
To expose the anterior joint capsule, the anterior region of the vastus lateralis needed forceful dissection of the muscles from the bone or lifting specks of bone where possible. Following anterior dissection down the greater trochanter and onto the femoral neck, the gluteus minimus capsule was freed from the anterior greater trochanter, allowing for simple hip dislocation.
To avoid problems or fractures, enough exposure and attentive soft-tissue manipulation were used. In patients with a sclerotic and constricted femoral canal, extra measures were used during femoral stem preparation [10]. To avoid femoral stem perforation, sequential reaming over guidewire was performed.
The patients are likely to get routine physical therapy for total hip replacement after surgery, including patient education, pain management, range of motion, and muscle-strengthening activities. Partially weight-bearing was allowed for the first 6 weeks, followed by full weight-bearing. Ten to twenty-one days after surgery, the patients were discharged from the hospital.
The most common intervention during pre-collapse phases is core decompression, which involves the surgical removal (by drilling) of damaged tissue from the interior of the femoral head to reduce pressure and enhance perfusion. Cell treatments have been utilized as adjuvants to core decompression. They have been found to be safe, with better clinical results and a lower rate of disease progression than core decompression alone [36, 37].
However, core decompression shows good results, and it is considered a good option for symptomatic small to medium-sized pre-collapse lesions. It is not recommended in case of a collapsed femoral head.
Bone grafting is a therapy option for more extensive lesions that do not collapse prematurely. The bone graft is likely to be obtained as a vascularized bone graft from another part of the patient’s body along with intact vasculature, an autograph from another part of the patient’s body, or an allograft from another person via a bone bank. The vascularized bone transplant has the extra benefit of transporting a fresh blood supply, which can help with revascularization and perhaps revitalize the necrotic zone.
The removal of segments of bone to change the weight distribution of the joint to the healthy, uninvolved bone is known as osteotomy. Angular intertrochanteric or rotational trans-trochanteric operations, in which the necrotic portion of the femoral head is shifted away from weight-bearing regions, supposedly enabling healing or slowing development [38], are common examples.
If the injury is severe, the hip has collapsed, and/or there is acetabular involvement, arthroplasty (removal of the ball-and-socket joint and replacement with a prosthesis) may be necessary [23]. While there have been improvements in hardware such as low-wear surface bearings that have significantly improved the outcome of hip replacement in the setting of osteonecrosis in the last 20 years [4], the outcome of hip replacement in the setting of osteonecrosis has previously shown mixed success rates.
The patients who underwent congruous hip joint radiologically were diagnosed to have infarct area > 30% through magnetic resonance imaging. These patients are likely to have previous joint preservation treatments (core decompression); however, pain alleviation did not seem to benefit from them. The patients undergoing an incongruent hip joint with arthritic alterations are likely to use an uncemented complete hip replacement (Figures 1–3).
(a) Preoperative hip joint with subchondral collapse and loss of acetabular congruency; (b) postoperative hip joint with a prosthesis.
(a) Preoperative hip joint with preserved acetabular congruency; (b) postoperative hip joint with a prosthesis.
Postsurgical head of the femurs; (a) Femur’s round head; (b) Femur’s triangular head.
Surgical treatment, such as total hip replacement, is the last resort to address the changes occurring in the hip joint due to a vascular necrosis and secondary osteoarthritis in sickle cell anemia, even though there are less invasive procedures such as core decompression and trap door procedure that can and should be offered earlier to alter the situation.
It is important to remember that the presence of soft tissue changes such as contracture or infection, as well as skeletal findings such as the loss of the medullary canal, variation in bone quality, bone load resistance, and spine vertebral segmental collapse with a vascular necrosis, all affect the outcome of total hip replacement. Patients with just hip joint alterations are likely to have a better prognosis, but those with multiple musculoskeletal changes are expected to have a range of outcomes.
There is the proportional correlation of medullary obliteration acetabular periarticular infarct (Figure 4a and b), spine vertebral column collapse with kyphoscoliosis (Figure 5), and soft tissue hip and knee contractures (Figure 6) with the severity of preoperative symptoms, postoperative Harris Hip Scores (HHSs), and intraoperative difficulties. Other characteristics contributing to a lower hip score include severe leg length disparity, obliteration of the medullary cavities, soft tissue contractures, and poor bone quality [39].
(a) Advanced bilateral a vascular necrosis away from hips; (b) unilateral a vascular necrosis restricted to the left hip.
Scoliosis of the spine secondary to a vascular necrosis.
Soft tissue hip and knee contractures.
Sickle cell disease is linked to a variety of orthopedic conditions, including femoral head osteonecrosis. Leg length difference is caused by lumbar spine involvement with osteonecrosis and collapse with subsequent sclerosis. Intraoperative blood loss should be avoided as feasible in patients with a high difficulty score, and blood transfusions should be administered as needed.
Sickle cell anemia is a kind of anemia that affects vascular necrosis, which affects the hip joint early in a patient’s life. As sickle cell anemia patients’ survival rates improve, it is more likely that hip replacement and revision procedures will be performed sooner than expected [40]. Infarcts cause most instances with boney infarct without loss of congruency with intraosseous compartmental pressure of the femoral head, which may benefit from core decompression [39]. Hips become complicated since the disease has deteriorated owing to weakness, stiffness, and a lack of desire by the time they present.
The time necessary for surgery is equivalent to the time required for a problematic main hip, and our findings are consistent with those of other writers. Technical challenges observed during surgery included the severity of localized disease alterations such as stiffness, femoral canal obliteration, and acetabular bone stock variation due to cysts, sclerosis, and protrusio in rare cases.
Intraoperative blood loss varies according to these technological challenges, necessitating more blood transfusions. Our study’s duration is longer than predicted compared with previous studies on primary total hip replacement (THR), which had mean operational times of 89 minutes and 12,328 minutes. The mean intraoperative blood loss was 1600 ml, more significant than the 1090 ml, 984 ml, and about 371 ml reported in primary THR.
The acetabulum of the femur can both be perforated and fractured. The individuals who had femoral perforation did not require any additional treatment. The channel was ultimately discovered, and the stem was able to avoid the hole. A sickler and a young guy with steroid-induced AVN both had acetabular perforation. Due to severe irregularity and a poor acetabular floor, the hole developed during reaming. In sicklers, Al-Mousawi [41] found acetabular perforation, femoral perforation, and fractures identical to our findings.
At birth, the hip joint lacks sphericity and congruency. It is also prone to subluxation and dislocations due to its lack of rigidity. A deeper spherical acetabular cavity occurs due to stress and musculoskeletal alterations, enhancing joint stability [42].
Osteoarthritis of the hip can be caused by various developmental disorders defined by a lack of hip joint congruency. However, femoroacetabular impingements might be a secondary cause of osteoarthritis [43]. Patients with a lack of congruency were thought to have more significant clinical problems, and complete hip replacement in these patients would result in substantial functional benefits.
After surgery, the patients got routine physical therapy for total hip replacement, including pain management, muscle-strengthening activities, patient education, and range of motion. Partially weight-bearing was allowed for the first 6 weeks, followed by full weight-bearing. Ten to twenty-one days after surgery, the patients were discharged from the hospital.
The functional results were assessed using the Harris Hip Score (HHS) [44]. To evaluate functional results clinically and radiographically, all patients were followed up at 6-week intervals and subsequently at 6-month intervals. Loosening, dislocation, and heterotopic ossification were all looked for on radiographs.
Surgical problems, infection, loosening, and dislocation were all considered failures, necessitating revision replacement surgery. Patients were examined by a hematologist and the research author at each follow-up, and medical and surgical problems were recorded.
A vascular necrosis of the femoral head symptoms coincides with other etiologies that should be considered in a differential diagnosis. The first is bone marrow edema syndrome (BMES), also known as temporary osteoporosis, which develops due to an accident, increased physical activity, or osteoarthritis. This syndrome manifests as sudden, atraumatic hip discomfort that is self-limited and usually fades within a year. Table 2.
Complex regional pain syndrome |
Inflammatory synovitis |
bone marrow edema syndrome (BMES) |
Osteomyelitis |
Osteoarthritis |
Osteoporosis |
Soft tissue trauma |
Problems faced by patients in osteonecrosis.
Magnetic resonance imaging or extensive bone marrow edema gives the condition its name; imaging is frequently essential [45]. A subchondral fracture, which commonly arises as a fracture following minor trauma in the elderly, in the setting of osteoporosis leading to subchondral insufficiency, is another disorder that can be mistaken with osteonecrosis of the proximal head of the femur.
Many variables influence the prognosis of femoral head osteonecrosis. The point at when it is diagnosed is one of them. The sooner an illness is diagnosed, the more successful the preventative measures are and the better the prognosis.
Moreover, there are markers of a poor prognosis such as lateral head involvement, age > 50 years, and involvement of greater than one-third of the weight-bearing portion of the femoral head, along with the disease advancement when the diagnosis is being made [46]. A patient’s prognosis might differ and should be decided by a skilled physician following an adequate examination; although, one or more of these characteristics are present [47].
Joint discomfort worsens with time, decreased range of motion, and osteoarthritis are all complications [48]. Patients may have a considerable handicap as a result of these consequences.
A trained orthopedic surgeon should be consulted for an expert examination when a practitioner believes a patient has femoral head osteonecrosis.
Patients should seek medical attention if patients are suffering discomfort in their hips, thighs, or buttocks. Specific patient populations should be informed of the risk factors and tested as appropriate because early a vascular necrosis of the femoral head might be asymptomatic.
Patients on long-term steroid treatment, long-term bisphosphonates, heavy alcohol usage, hemoglobinopathies, chemotherapy or radiation patients, and those who sustain damage to the hip and surrounding region are all examples of higher-risk patients [23].
Many inter-professional individuals’ makeup healthcare teams, including (but not limited to) a physician, nurse practitioner or physician assistant, pharmacist, and nurse. All members of this team who treat patients with a vascular necrosis of the femoral head must recognize the problem, engage in a qualified care plan, and seek expert advice when necessary. The pharmacist can assist in evaluating drug regimens, both in the lead-up to AVN and in attempts to treat AVN pharmaceutically, and can report any concerns to the physician.
If surgery is required, an orthopedic specialist will lead the treatment, and nursing will assist in preparing the patient for surgery, monitoring the patient during and after surgery, and checking on treatment efficacy as well as administering postoperative medications, all while keeping an eye out for adverse effects that should be reported as soon as possible.
Patients should be educated about the dangers of drinking by primary care providers, especially nurses. In addition, doctors should use the lowest effective dosage of corticosteroids when prescribing them. Patients taking long-term corticosteroids should be queried about hip discomfort at every clinic visit by nurses and doctors. The pharmacist should educate patients about the importance of quitting smoking and collaborate with physicians to develop pharmacological aids to help smokers quit. Patients should be educated on the signs and symptoms of AVN to seek treatment as soon as possible.
Each inter-professional healthcare team member’s awareness and knowledge of a vascular necrosis of the femoral head will enhance patient treatment and prognosis outcomes.
In sickle cell anemia patients, the primary total hip should be adequately prepared; we believe lumping all sickle cell hip a vascular necrosis together is unjust to patients and surgeons. While some of these individuals may be treated with ease, others have a greater degree of difficulty, as evidenced by the existence of musculoskeletal alterations that are not limited to the hip joint.
A thorough history, physical, and radiological examination focusing on these predictors of poor prognosis are required to distinguish between the two groups. Strict preoperative optimization is needed, as well as a well-stocked implant arsenal for hip replacement. Technically, the hips of sickle cell anemia patients with a high difficulty index are complex; challenges should be anticipated and addressed to minimize a high rate of intraoperative problems, increased operation duration, and blood loss. Primary hip replacement in sickle cell disease patients is prevalent and might be challenging to do.
The author is thankful to all the associated personnel who contributed for this study by any means.
There is no conflict of interest.
None.
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