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Arn Roth T, Jokeit M, Sutter R, Vlachopoulos L, Fucentese SF, Carrillo F, Snedeker JG, Esfandiari H, Fürnstahl P. Deep-learning based 3D reconstruction of lower limb bones from biplanar radiographs for preoperative osteotomy planning. Int J Comput Assist Radiol Surg 2024; 19:1843-1853. [PMID: 38573567 DOI: 10.1007/s11548-024-03110-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 03/08/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Three-dimensional (3D) preoperative planning has become the gold standard for orthopedic surgeries, primarily relying on CT-reconstructed 3D models. However, in contrast to standing radiographs, a CT scan is not part of the standard protocol but is usually acquired for preoperative planning purposes only. Additionally, it is costly, exposes the patients to high doses of radiation and is acquired in a non-weight-bearing position. METHODS In this study, we develop a deep-learning based pipeline to facilitate 3D preoperative planning for high tibial osteotomies, based on 3D models reconstructed from low-dose biplanar standing EOS radiographs. Using digitally reconstructed radiographs, we train networks to localize the clinically required landmarks, separate the two legs in the sagittal radiograph and finally reconstruct the 3D bone model. Finally, we evaluate the accuracy of the reconstructed 3D models for the particular application case of preoperative planning, with the aim of eliminating the need for a CT scan in specific cases, such as high tibial osteotomies. RESULTS The mean Dice coefficients for the tibial reconstructions were 0.92 and 0.89 for the right and left tibia, respectively. The reconstructed models were successfully used for clinical-grade preoperative planning in a real patient series of 52 cases. The mean differences to ground truth values for mechanical axis and tibial slope were 0.52° and 4.33°, respectively. CONCLUSIONS We contribute a novel framework for the 2D-3D reconstruction of bone models from biplanar standing EOS radiographs and successfully use them in automated clinical-grade preoperative planning of high tibial osteotomies. However, achieving precise reconstruction and automated measurement of tibial slope remains a significant challenge.
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Affiliation(s)
- Tabitha Arn Roth
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland.
- Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Balgrist Campus, Lengghalde 5, 8008, Zurich, Switzerland.
| | - Moritz Jokeit
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Fabio Carrillo
- Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Balgrist Campus, Lengghalde 5, 8008, Zurich, Switzerland
| | | | - Hooman Esfandiari
- Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Balgrist Campus, Lengghalde 5, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Balgrist Campus, Lengghalde 5, 8008, Zurich, Switzerland
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Zindel C, Hodel S, Fürnstahl P, Schweizer A, Fucentese SF, Vlachopoulos L. Dome versus single-cut osteotomies for correction of long bone deformities-technical considerations. Sci Rep 2024; 14:12839. [PMID: 38834604 DOI: 10.1038/s41598-024-62410-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/16/2024] [Indexed: 06/06/2024] Open
Abstract
Corrective osteotomy allows to improve joint loading, pain and function. In complex deformities, the biggest challenge is to define the optimal surgical solution, while considering anatomical, technical and biomechanical factors. While the single-cut osteotomy (SCOT) and focal dome osteotomy (FDO) are well-established treatment options, their mathematical relationship remain largely unclear. The aim of the study was (1) to describe the close mathematical relationship between the SCOT and FDO and (2) to analyze and introduce a novel technique-the stepped FDO-as a modification of the classic FDO. The mathematical background and relationship of SCOT and FDO are described for the example of a femoral deformity correction and visualized using a 3D surface model taking into account the benefits for the clinical application. The novel modifications of the stepped FDO are introduced and its technical and clinical feasibility demonstrated. Both, SCOT and FDO, rely on the same deformity axis that defines the rotation axis k for a 3D deformity correction. To achieve the desired correction using a SCOT, the resulting cutting plane is perpendicular to k, while using a FDO will result in a cylindrical cut with a central axis parallel to k. The SCOT and FDO demonstrate a strong mathematical relation, as both methods rely on the same deformity axis, however, resulting in different cutting planes. These characteristics enable a complementary use when defining the optimal type of osteotomy. This understanding enables a more versatile planning approach when considering factors as the surgical approach, biomechanical characteristics of fixation or soft tissue conditions. The newly introduced stepped FDO facilitates an exact reduction of the bone fragments and potentially expands the clinical applicability of the FDO.
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Affiliation(s)
- Christoph Zindel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Sandro Hodel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist CAMPUS, Zurich, Switzerland
| | - Andreas Schweizer
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Hodel S, Arn-Roth T, Haug F, Carillo F, Vlachopoulos L, Fucentese SF, Fürnstahl P. The influence of the weight-bearing state on three-dimensional (3D) planning in lower extremity realignment - analysis of novel vs. state-of-the-art planning approaches. Arch Orthop Trauma Surg 2024; 144:1989-1996. [PMID: 38554205 PMCID: PMC11093806 DOI: 10.1007/s00402-024-05289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/17/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND The use of 3D planning to guide corrective osteotomies of the lower extremity is increasing in clinical practice. The use of computer-tomography (CT) data acquired in supine position neglects the weight-bearing (WB) state and the gold standard in 3D planning involves the manual adaption of the surgical plan after considering the WB state in long-leg radiographs (LLR). However, this process is subjective and dependent on the surgeons experience. A more standardized and automated method could reduce variability and decrease costs. PURPOSE The aim of the study was (1) to compare three different three-dimensional (3D) planning modalities for medial open-wedge high tibial osteotomy (MOWHTO) and (2) to describe the current practice of adapting NWB CT data after considering the WB state in LLR. The purpose of this study is to validate a new, standardized approach to include the WB state into the 3D planning and to compare this method against the current gold standard of 3D planning. Our hypothesis is that the correction is comparable to the gold standard, but shows less variability due compared to the more subjective hybrid approach. METHODS Three surgical planning modalities were retrospectively analyzed in 43 legs scheduled for MOWHTO between 2015 and 2019. The planning modalities included: (1) 3D hybrid (3D non-weight-bearing (NWB) CT models after manual adaption of the opening angle considering the WB state in LLR, (2) 3D NWB (3D NWB CT models) and (3) 3D WB (2D/3D registration of 3D NWB CT models onto LLR to simulate the WB state). The pre- and postoperative hip-knee-ankle angle (HKA) and the planned opening angle (°) were assessed and differences among modalities reported. The relationship between the reported differences and BMI, preoperative HKA (LLR), medial meniscus extrusion, Outerbridge osteoarthritis grade and joint line convergence angle (JLCA) was analyzed. RESULTS The mean (std) planned opening angle of 3D hybrid did not differ between 3D hybrid and 3D WB (0.4 ± 2.1°) (n.s.) but was higher in 3D hybrid compared to 3D NWB (1.1° ± 1.1°) (p = 0.039). 3D WB demonstrated increased preoperative varus deformity compared to 3D NWB: 6.7 ± 3.8° vs. 5.6 ± 2.7° (p = 0.029). Patients with an increased varus deformity in 3D WB compared to 3D NWB (> 2 °) demonstrated more extensive varus alignment in LLR (p = 0.009) and a higher JLCA (p = 0.013). CONCLUSION Small intermodal differences between the current practice of the reported 3D hybrid planning modality and a 3D WB approach using a 2D/3D registration algorithm were reported. In contrast, neglecting the WB state underestimates preoperative varus deformity and results in a smaller planned opening angle. This leads to potential under correction in MOWHTO, especially in patients with extensive varus deformities or JLCA. CLINICAL RELEVANCE Incorporating the WB state in 3D planning modalities has the potential to increase accuracy and lead to a more consistent and reliable planning in MOWHTO. The inclusion of the WB state in automatized surgical planning algorithms has the potential to reduce costs and time in the future.
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Affiliation(s)
- Sandro Hodel
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland.
| | - Tabitha Arn-Roth
- Balgrist University Hospital, Research in Orthopaedics Computer Science, University of Zurich, Balgrist Forchstrasse 340, Zurich, 8008, Switzerland
| | - Florian Haug
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland
| | - Fabio Carillo
- Balgrist University Hospital, Research in Orthopaedics Computer Science, University of Zurich, Balgrist Forchstrasse 340, Zurich, 8008, Switzerland
| | - Lazaros Vlachopoulos
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland
| | - Sandro F Fucentese
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland
| | - Philipp Fürnstahl
- Balgrist University Hospital, Research in Orthopaedics Computer Science, University of Zurich, Balgrist Forchstrasse 340, Zurich, 8008, Switzerland
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Vlachopoulos L, Fucentese SF. [Osteotomies around the knee: preoperative planning using CT-based three-dimensional analysis, patient-specific cutting and reduction guides]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:225-238. [PMID: 37316574 PMCID: PMC10520128 DOI: 10.1007/s00064-023-00814-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/03/2023] [Accepted: 02/07/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The goal of osteotomy is either to restore pretraumatic anatomic conditions or to shift the load to less affected compartments. INDICATIONS Indications for computer-assisted 3D analysis and the use of patient-specific osteotomy and reduction guides include "simple" deformities and, in particular, multidimensional complex (especially posttraumatic) deformities. CONTRAINDICATIONS General contraindications for performing a computed tomography (CT) scan or for an open approach for performing the surgery. SURGICAL TECHNIQUE Based on CT examinations of the affected and, if necessary, the contralateral healthy extremity as a healthy template (including hip, knee, and ankle joints), 3D computer models are generated, which are used for 3D analysis of the deformity as well as for calculation of the correction parameters. For the exact and simplified intraoperative implementation of the preoperative plan, individualized guides for the osteotomy and the reduction are produced by 3D printing. POSTOPERATIVE MANAGEMENT Partial weight-bearing from the first postoperative day. Increasing load after the first x‑ray control 6 weeks postoperatively. No limitation of the range of motion. RESULTS There are several studies that have analyzed the accuracy of the implementation of the planned correction for corrective osteotomies around the knee joint with the use of patient-specific instruments with promising results.
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Affiliation(s)
- Lazaros Vlachopoulos
- Klinik für Orthopädie, Universitätsklinik Balgrist, Universität Zürich, Forchstr. 340, 8008, Zürich, Schweiz.
| | - Sandro F Fucentese
- Klinik für Orthopädie, Universitätsklinik Balgrist, Universität Zürich, Forchstr. 340, 8008, Zürich, Schweiz
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Cozzolino A, Guastafierro A, Bernasconi A, Della Rotonda G, Malfi P, Fedele A, Mortellaro M, Minopoli P, Pietroluongo LR, Russo R. Proximal humerus fracture sequelae: are corrective osteotomies still a taboo? The role of three-dimensional preoperative planning and patient-specific surgical guides for proximal humerus corrective osteotomy in combination with reverse shoulder arthroplasty. JSES Int 2022; 7:104-112. [PMID: 36820410 PMCID: PMC9937839 DOI: 10.1016/j.jseint.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Symptomatic proximal humeral fracture sequelae (PHFS) represent a surgical challenge due to the altered bone and soft tissue morphology. The purpose of this study was to report the outcome of Multiplanar Corrective Humeral Osteotomies (MCHOs) in combination with reverse total shoulder arthroplasty (rTSA) performed following a three-dimensional (3D) preoperative planning and using a 3D-printed patient-specific surgical instrumentation (PSI) in type 1C, 1D, and 4 PHFS. Methods In this prospective monocentric study, we enrolled patients affected by symptomatic PHFS type 1C, 1D, or 4 of Boileau's classification, treated between 2018 and 2019 with rTSA associated to MCHO and followed-up at 12 and 24 mo. The preoperative and postoperative Constant Score (CS), visual analog scale, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded. All patients underwent a preoperative computed tomography, then a dedicated software was used to run a segmentation algorithm on computed tomography images. Metaphyseal bone cuts were virtually performed before surgery in all patients, and a 3D-printed PSI was used to reproduce the planned osteotomies in vivo. Results Twenty patients completed a 2-y follow-up. The mean (± standard deviation) CS, visual analog scale, and DASH values improve from 24.3 (± 8.8), 6.5 (± 1.3), 60.7 (± 9.6) preoperatively, to 67.7 (± 11.4), 1.6 (± 0.8), 24.1 (± 13.1) points after surgery, respectively. The minimally clinical important difference for CS and DASH score was achieved in 95% of patients. No major complication was observed. One patient showed an unexplained worsening of clinical scores between the 12 and the 24-mo follow-up, while in one patient bone resorption of the greater tuberosity was observed on radiographs at 2 y, with no clinical impact. Conclusion The combination of preoperative 3D planning and intraoperative use of 3D-printed PSI to perform MCHO as concurrent procedure in the context of rTSA in the treatment of Boileau type 1C, 1D, and 4 PHFS may lead to a satisfactory clinical outcome at 2 y of follow-up.
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Affiliation(s)
- Andrea Cozzolino
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | - Alessio Bernasconi
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | | | - Alfonso Fedele
- Department of Orthopedic Surgery, Pineta Grande Hospital, Castelvolturno, Italy
| | - Marco Mortellaro
- Department of Orthopedic Surgery, Pineta Grande Hospital, Castelvolturno, Italy
| | - Paolo Minopoli
- Department of Orthopedic Surgery, Pineta Grande Hospital, Castelvolturno, Italy
| | | | - Raffaele Russo
- Department of Public Health, University of Naples Federico II, Naples, Italy,Corresponding author: Raffaele Russo, MD, Department of Orthopedic Surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy.
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Yoshii Y, Iwahashi Y, Sashida S, Shrestha P, Shishido H, Kitahara I, Ishii T. An Experimental Study of a 3D Bone Position Estimation System Based on Fluoroscopic Images. Diagnostics (Basel) 2022; 12:diagnostics12092237. [PMID: 36140638 PMCID: PMC9497817 DOI: 10.3390/diagnostics12092237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/01/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
To compare a 3D preoperative planning image and fluoroscopic image, a 3D bone position estimation system that displays 3D images in response to changes in the position of fluoroscopic images was developed. The objective of the present study was to evaluate the accuracy of the estimated position of 3D bone images with reference to fluoroscopic images. Bone positions were estimated from reference points on a fluoroscopic image compared with those on a 3D image. The four reference markers positional relationships on the fluoroscopic image were compared with those on the 3D image to evaluate whether a 3D image may be drawn by tracking positional changes in the radius model. Intra-class correlations coefficients for reference marker distances between the fluoroscopic image and 3D image were 0.98–0.99. Average differences between measured values on the fluoroscopic image and 3D bone image for each marker corresponding to the direction of the bone model were 1.1 ± 0.7 mm, 2.4 ± 1.8 mm, 1.4 ± 0.8 mm, and 2.0 ± 1.6 mm in the anterior-posterior view, ulnar side lateral view, posterior-anterior view, and radial side lateral view, respectively. Marker positions were more accurate in the anterior-posterior and posterior-anterior views than in the radial and ulnar side lateral views. This system helps in real-time comparison of dynamic changes in preoperative 3D and intraoperative fluoroscopy images.
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Affiliation(s)
- Yuichi Yoshii
- Department of Orthopedic Surgery, Tokyo Medical University Ibaraki Medical Center, Ami, Ibaraki 300-0398, Japan
- Correspondence: ; Tel.: +81-298871161
| | | | | | - Pragyan Shrestha
- Center for Computational Sciences, Tsukuba University, Tsukuba, Ibaraki 305-8577, Japan
| | - Hidehiko Shishido
- Center for Computational Sciences, Tsukuba University, Tsukuba, Ibaraki 305-8577, Japan
| | - Itaru Kitahara
- Center for Computational Sciences, Tsukuba University, Tsukuba, Ibaraki 305-8577, Japan
| | - Tomoo Ishii
- Department of Orthopedic Surgery, Tokyo Medical University Ibaraki Medical Center, Ami, Ibaraki 300-0398, Japan
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Hodel S, Torrez C, Hoch A, Fürnstahl P, Vlachopoulos L, Fucentese SF. Increased femoral curvature and trochlea flexion in high-grade patellofemoral dysplastic knees. Knee Surg Sports Traumatol Arthrosc 2022; 31:1361-1369. [PMID: 35920842 DOI: 10.1007/s00167-022-07080-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE High-grade patellofemoral dysplasia is often associated with concomitant axial and frontal leg malalignment. However, curvature of the femur and sagittal flexion of the trochlea has not yet been studied in patellofemoral dysplastic knees. The aim of the study was to quantify the femoral curvature and sagittal flexion of the trochlea in both high-grade patellofemoral dysplastic and healthy knees. METHODS A retrospective case-control study matched 19 high-grade patellofemoral dysplastic knees (Dejour types C and D) with 19 healthy knees according to sex and body mass index. Three-dimensional (3D) femoral curvature and sagittal trochlea flexion were analysed. To analyse femoral curvature, the specific 3D radius of curvature (ROC) was calculated. Trochlear flexion was quantified through the development of the trochlea flexion angle (TFA), which is a novel 3D measurement in relation to the anatomical and mechanical femur axis and is referred to as 3D TFAanatomic and 3D TFAmech. The influence of age, gender, height, weight and frontal and axial alignment on ROC and TFA was analysed in a multiple regression model. RESULTS Overall ROC was significantly smaller in dysplastic knees, compared with the control group [898.4 ± 210.8 mm (range 452.9-1275.1 mm) vs 1308.4 ± 380.5 mm (range 878.3-2315.8 mm), p < 0.001]. TFA was significantly higher in dysplastic knees, compared with the control group, for 3D TFAmech [13.8 ± 7.2° (range 4.4-33.4°) vs 6.5 ± 2.3° (range 0.8-10.2°), p < 0.001] and 3D TFAanatomic [12.5 ± 7.2° (range 3.1-32.2°) vs 6.4 ± 1.9° (range 2.1-9.1°), p = 0.001]. A smaller ROC was associated with smaller height, female gender and higher femoral ante torsion. An increased TFA was associated with valgus malalignment. CONCLUSION High-grade patellofemoral dysplastic knees demonstrated increased femoral curvature and sagittal flexion of the trochlea, compared with healthy knees. The ROC and newly described TFA allowed the quantification of the sagittal femoral deformity. TFA and ROC should be incorporated in future deformity analysis to investigate their potential as a target for surgical correction. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Carlos Torrez
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Armando Hoch
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Head of Research in Orthopedic Computer Science (ROCS), University Hospital Balgrist, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Russo R, Cozzolino A, Guastafierro A, Della Rotonda G, Viglione S, Ciccarelli M, Mortellaro M, Minopoli P, Fiorentino F, Pietroluongo LR. Use of 3D Planning and Patient-specific Guides for Proximal Humerus Corrective Osteotomy Associated With Shoulder Prosthesis Implantation in Proximal Humeral Varus Malunion. Tech Hand Up Extrem Surg 2022; 26:131-138. [PMID: 34753888 DOI: 10.1097/bth.0000000000000372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Humeral stem prosthesis implantation in case of proximal humerus varus malunion (type 1D fracture sequelae) is often complicated by greater tuberosity fracture and by posterosuperior rotator cuff iatrogenic damage. Moreover, the varus malunited humeral head could lead to scapular impingement and reduce the range of motion. To address this problem, we introduced a new surgical procedure consisting in a proximal humerus osteotomy, planned with three-dimensional (3D) preoperative virtual surgery, and performed with patient-specific surgical guides, to correct humerus deformity before the implantation of the prosthetic humeral stem. A 3D evaluation of the deformity, based on the comparison to the healthy contralateral side or to anatomical standard values, is firstly performed. The metaphyseal osteotomy is then planned and virtually performed. To faithfully reproduce the planned correction, 3D printed surgical guides are prepared. Before the surgery, it is advisable to perform a simulation of the planned osteotomies to verify their real feasibility and to find any critical issues. Preliminary outcomes of this surgical technique are encouraging, but formal studies are warranted to validate its clinical utility and longevity of results.
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Affiliation(s)
- Raffaele Russo
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta
| | - Andrea Cozzolino
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta
| | | | | | - Stefano Viglione
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta
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Reid JS, Vanderkarr M, Ray B, Chitnis A, Holy CE, Sparks C. Two-year clinical and economic burden, risk and outcomes following application of software-assisted hexapod ring fixation systems. BMC Musculoskelet Disord 2022; 23:25. [PMID: 34980051 PMCID: PMC8725345 DOI: 10.1186/s12891-021-04934-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/02/2021] [Indexed: 11/30/2022] Open
Abstract
Background Multiplanar external fixation systems that employ software-assisted deformity correction consist of rings connected by angled struts, defined as hexapod ring fixators (HRF). Costs and outcomes associated with the application of HRFs are not well documented. This study was designed to provide a nationwide baseline understanding of the clinical presentation, risks, outcomes and payer costs, and healthcare resource utilization (HCU) of patients requiring application of an HRF, from the day of, and up to 2 years, post-application. Methods Patients with HRF application (“index”) between 2007 and 2019 within the IBM Marketscan® Commercial Claims database were identified and categorized based on diagnosis: acquired deformity, arthropathy, congenital deformity, deep infection, nonunion, fracture, and other post-operative fracture sequelae. Demographics, comorbidities at index, complications post-index, HCU, and payments were analyzed. Payments were estimated using a generalized linear model and were adjusted for inflation to the 2020 consumer price index. Rates of deep infection and amputation were estimated up to 2 years post-index using Poisson regressions, and risk factors for each were estimated using logistic regression models. Results Six hundred ninety-five patients were included in our study (including 219 fractures, 168 congenital deformities, 68 deep infections, 103 acquired deformities). Comorbidities at index were significantly different across groups: less than 2% pediatrics vs 18% adults had 3 or more comorbidities, < 1% pediatric vs 29% adults had diabetes. Index payments ranged from $39,250–$75,350, with 12-months post-index payments ranging from $14,350 to $43,108. The duration of the HRF application ranged from 96 days to 174 days. Amputation was observed in patients with deep infection (8.9, 95% confidence interval (CI): 3.2–23.9%), nonunion (5.0, 95%CI: 1.6–15.4%) or fracture (2.7, 95%CI: 0.9–7.6%) at index. Complicated diabetes was the main predictor for deep infection (odds ratio (OR): 5.14, 95%CI: 2.50–10.54) and amputation (OR: 5.26, 95%CI: 1.79–15.51). Conclusions Findings from this longitudinal analysis demonstrate the significant heterogeneity in patients treated with HRF, and the wide range in treatment intensity, payments, and outcomes. Risks for deep infection and amputation were primarily linked to the presence of complicated diabetes at the time of HRF application, suggesting a need for careful management of comorbid chronic conditions in patients requiring HRF for orthopedic care.
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Affiliation(s)
| | | | | | - Abhishek Chitnis
- Real World Data Sciences, Medical Device Epidemiology, Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, USA
| | - Chantal E Holy
- Real World Data Sciences, Medical Device Epidemiology, Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, USA.
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Flury A, Hasler J, Beeler S, Imhoff FB, Wirth SH, Viehöfer A. Talus morphology differs between flatfeet and controls, but its variety has no influence on extent of surgical deformity correction. Arch Orthop Trauma Surg 2022; 142:3103-3110. [PMID: 33970321 PMCID: PMC9522700 DOI: 10.1007/s00402-021-03925-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/29/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND Progressive collapsing foot deformity (PCFD) is a complex 3-dimensional (3-D) deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. The first aim of this study was to perform a 3-D analysis of the talus morphology between symptomatic PCFD patients that underwent operative flatfoot correction and controls. The second aim was to investigate if there is an impact of individual talus morphology on the success of operative flatfoot correction. METHODS We reviewed all patients that underwent lateral calcaneal lengthening for correction of PCFD between 2008 and 2018 at our clinic. Radiographic flatfoot parameters on preoperative and postoperative radiographs were assessed. Additionally, 3-D surface models of the tali were generated using computed tomography (CT) data. The talus morphology of 44 flatfeet was compared to 3-D models of 50 controls without foot or ankle pain of any kind. RESULTS Groups were comparable regarding demographics. Talus morphology differed significantly between PCFD and controls in multiple aspects. There was a 2.6° increased plantar flexion (22.3° versus 26°; p = 0.02) and medial deviation (31.7° and 33.5°; p = 0.04) of the talar head in relation to the body in PCFD patients compared to controls. Moreover, PCFD were characterized by an increased valgus (difference of 4.6°; p = 0.01) alignment of the subtalar joint. Satisfactory correction was achieved in all cases, with an improvement of the talometatarsal-angle and the talonavicular uncoverage angle of 5.6° ± 9.7 (p = 0.02) and 9.9° ± 16.3 (p = 0.001), respectively. No statistically significant correlation was found between talus morphology and the correction achieved or loss of correction one year postoperatively. CONCLUSION The different morphological features mentioned above might be contributing or risk factors for progression to PCFD. However, despite the variety of talar morphology, which is different compared to controls, the surgical outcome of calcaneal lengthening osteotomy was not affected. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Andreas Flury
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Julian Hasler
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Silvan Beeler
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Florian B Imhoff
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Stephan H Wirth
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Arndt Viehöfer
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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11
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Casari FA, Navab N, Hruby LA, Kriechling P, Nakamura R, Tori R, de Lourdes Dos Santos Nunes F, Queiroz MC, Fürnstahl P, Farshad M. Augmented Reality in Orthopedic Surgery Is Emerging from Proof of Concept Towards Clinical Studies: a Literature Review Explaining the Technology and Current State of the Art. Curr Rev Musculoskelet Med 2021; 14:192-203. [PMID: 33544367 PMCID: PMC7990993 DOI: 10.1007/s12178-021-09699-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Augmented reality (AR) is becoming increasingly popular in modern-day medicine. Computer-driven tools are progressively integrated into clinical and surgical procedures. The purpose of this review was to provide a comprehensive overview of the current technology and its challenges based on recent literature mainly focusing on clinical, cadaver, and innovative sawbone studies in the field of orthopedic surgery. The most relevant literature was selected according to clinical and innovational relevance and is summarized. RECENT FINDINGS Augmented reality applications in orthopedic surgery are increasingly reported. In this review, we summarize basic principles of AR including data preparation, visualization, and registration/tracking and present recently published clinical applications in the area of spine, osteotomies, arthroplasty, trauma, and orthopedic oncology. Higher accuracy in surgical execution, reduction of radiation exposure, and decreased surgery time are major findings presented in the literature. In light of the tremendous progress of technological developments in modern-day medicine and emerging numbers of research groups working on the implementation of AR in routine clinical procedures, we expect the AR technology soon to be implemented as standard devices in orthopedic surgery.
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Affiliation(s)
- Fabio A Casari
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
- ROCS, Research in Orthopedic Computer Science, Balgrist Campus, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland.
| | - Nassir Navab
- Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany
- Computer Aided Medical Procedures (CAMP), Johns Hopkins University, Baltimore, MD, USA
| | - Laura A Hruby
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Kriechling
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ricardo Nakamura
- Computer Engineering and Digital Systems Department, Escola Politécnica, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Romero Tori
- Computer Engineering and Digital Systems Department, Escola Politécnica, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Marcelo C Queiroz
- Orthopedics and Traumatology Department, Faculty of Medical Sciences of Santa Casa de Sao Paulo, Sao Paulo, SP, Brazil
| | - Philipp Fürnstahl
- ROCS, Research in Orthopedic Computer Science, Balgrist Campus, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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12
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Zindel C, Fürnstahl P, Hoch A, Götschi T, Schweizer A, Nagy L, Roner S. Inter-rater variability of three-dimensional fracture reduction planning according to the educational background. J Orthop Surg Res 2021; 16:159. [PMID: 33632251 PMCID: PMC7905543 DOI: 10.1186/s13018-021-02312-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/17/2021] [Indexed: 11/18/2022] Open
Abstract
Background Computer-assisted three-dimensional (3D) planning is increasingly delegated to biomedical engineers. So far, the described fracture reduction approaches rely strongly on the performance of the users. The goal of our study was to analyze the influence of the two different professional backgrounds (technical and medical) and skill levels regarding the reliability of the proposed planning method. Finally, a new fragment displacement measurement method was introduced due to the lack of consistent methods in the literature. Methods 3D bone models of 20 distal radius fractures were presented to nine raters with different educational backgrounds (medical and technical) and various levels of experience in 3D operation planning (0 to 10 years) and clinical experience (1.5 to 24 years). Each rater was asked to perform the fracture reduction on 3D planning software. Results No difference was demonstrated in reduction accuracy regarding rotational (p = 1.000) and translational (p = 0.263) misalignment of the fragments between biomedical engineers and senior orthopedic residents. However, a significantly more accurate planning was performed in these two groups compared with junior orthopedic residents with less clinical experience and no 3D planning experience (p < 0.05). Conclusion Experience in 3D operation planning and clinical experience are relevant factors to plan an intra-articular fragment reduction of the distal radius. However, no difference was observed regarding the educational background (medical vs. technical) between biomedical engineers and senior orthopedic residents. Therefore, our results support the further development of computer-assisted surgery planning by biomedical engineers. Additionally, the introduced fragment displacement measure proves to be a feasible and reliable method. Level of Evidence Diagnostic Level II
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Affiliation(s)
- Christoph Zindel
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist CAMPUS, Zurich, Switzerland. .,Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist CAMPUS, Zurich, Switzerland
| | - Armando Hoch
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist CAMPUS, Zurich, Switzerland.,Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tobias Götschi
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Andreas Schweizer
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ladislav Nagy
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Simon Roner
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist CAMPUS, Zurich, Switzerland.,Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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13
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Dobbe JGG, Peymani A, Roos HAL, Beerens M, Streekstra GJ, Strackee SD. Patient-specific plate for navigation and fixation of the distal radius: a case series. Int J Comput Assist Radiol Surg 2021; 16:515-524. [PMID: 33575933 PMCID: PMC7946677 DOI: 10.1007/s11548-021-02320-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/26/2021] [Indexed: 11/28/2022]
Abstract
Purpose Corrective osteotomy of a malunited distal radius conventionally relies on 2D imaging techniques for alignment planning and evaluation. However, this approach results in suboptimal bone repositioning, which is associated with poor patient outcomes. In this case series, we evaluate the use of novel patient-specific plates (PSPs), which feature navigation and fixation of bone segments as preoperatively planned in 3D. Methods Ten participants with distal radius malunion underwent CT scans for preoperative alignment planning. Patient-specific guides and plates were designed, 3D-printed, and sterilized for use in corrective surgery of the distal radius. Pre- and postoperative results were compared in regard to clinical, functional, and radiographic outcomes. Results The application of a PSP was successful in 7 of the 10 cases. After treatment, the residual alignment error was reduced by approximately 50% compared with conventional treatment. The use of PSPs reduced pain significantly. Pre- and postoperative results were pooled and demonstrated significant correlations between: (1) pain and malpositioning, (2) the range of pro- and supination motion, the MHOQ score, the EQ-5D-5L score and dorsovolar angulation, and (3) MHOQ score and proximodistal translation. Conclusion The correlation between malalignment and MHOQ score, EQ-5D-5L score, pain, and range of motion shows that alignment should be restored as well as possible. Compared to the conventional approach, which relies on 2D imaging techniques, corrective osteotomy based on 3D preoperative planning and intraoperative fixation with a PSP has been shown to improve bone alignment and reduce pain. Level of evidence IV.
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Affiliation(s)
- Johannes G G Dobbe
- Department of Biomedical Engineering and Physics, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Room No L0-113-3, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Abbas Peymani
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Hendrika A L Roos
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Maikel Beerens
- Xilloc Medical, Urmonderbaan 22, Sittard-Geleen, The Netherlands
| | - Geert J Streekstra
- Department of Biomedical Engineering and Physics, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Room No L0-113-3, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Simon D Strackee
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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14
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Flury A, Jud L, Hoch A, Camenzind RS, Fucentese SF. Linear influence of distal femur osteotomy on the Q-angle: one degree of varization alters the Q-angle by one degree. Knee Surg Sports Traumatol Arthrosc 2021; 29:540-545. [PMID: 32274549 DOI: 10.1007/s00167-020-05970-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The effect of a distal femur varization osteotomy on patellofemoral biomechanics in genu valgum is unknown. The purpose of this study was to quantify the influence of frontal leg axis correction on the Q-angle with a novel three-dimensional (3-D) measurement method. METHODS 3-D surface models of ten lower extremities were generated using patient computed tomography (CT) data. The preoperative 3-D Q-angle was measured using a novel defined and validated 3-D measurement method. Biplanar supracondylar osteotomies were simulated with different degrees of varus correction (from 1° to 15°) in one-degree steps beginning from the preoperative valgus deformity, resulting in a total of 150 simulations. Additionally, mechanical leg axis and 3-D Q-angle measurements were performed on 3-D surface models of the postoperative CT scans of the same individuals. Further, pre- and postoperative TT-TG distance was measured. RESULTS Mean preoperative Q-angle was 15.8 ± 3.9° (range 10°-21.4°) with a mean preoperative mechanical leg axis of 6.5° ± 2.4 valgus (range 3.8°-11.6° valgus). The Q-angle changed linearly 0.9 ± 0° per 1° of varization. No difference was detected between simulated 3-D Q-angles and effectively corrected postoperative values (n.s.). TT-TG distance changed irregularly and minimally, and with no correlation to the degree of varization. CONCLUSION Distal femur varization osteotomy has a linear effect on the Q-angle with a change of 1° per 1° of varization. The difference in TT-TG distance was mainly due to an unintentional rotational component implemented during surgery.
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Affiliation(s)
- A Flury
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - L Jud
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - A Hoch
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - R S Camenzind
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - S F Fucentese
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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15
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Han R, Uneri A, Vijayan RC, Wu P, Vagdargi P, Sheth N, Vogt S, Kleinszig G, Osgood GM, Siewerdsen JH. Fracture reduction planning and guidance in orthopaedic trauma surgery via multi-body image registration. Med Image Anal 2020; 68:101917. [PMID: 33341493 DOI: 10.1016/j.media.2020.101917] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/16/2020] [Accepted: 11/23/2020] [Indexed: 02/06/2023]
Abstract
PURPOSES Surgical reduction of pelvic fracture is a challenging procedure, and accurate restoration of natural morphology is essential to obtaining positive functional outcome. The procedure often requires extensive preoperative planning, long fluoroscopic exposure time, and trial-and-error to achieve accurate reduction. We report a multi-body registration framework for reduction planning using preoperative CT and intraoperative guidance using routine 2D fluoroscopy that could help address such challenges. METHOD The framework starts with semi-automatic segmentation of fractured bone fragments in preoperative CT using continuous max-flow. For reduction planning, a multi-to-one registration is performed to register bone fragments to an adaptive template that adjusts to patient-specific bone shapes and poses. The framework further registers bone fragments to intraoperative fluoroscopy to provide 2D fluoroscopy guidance and/or 3D navigation relative to the reduction plan. The framework was investigated in three studies: (1) a simulation study of 40 CT images simulating three fracture categories (unilateral two-body, unilateral three-body, and bilateral two-body); (2) a proof-of-concept cadaver study to mimic clinical scenario; and (3) a retrospective clinical study investigating feasibility in three cases of increasing severity and accuracy requirement. RESULTS Segmentation of simulated pelvic fracture demonstrated Dice coefficient of 0.92±0.06. Reduction planning using the adaptive template achieved 2-3 mm and 2-3° error for the three fracture categories, significantly better than planning based on mirroring of contralateral anatomy. 3D-2D registration yielded ~2 mm and 0.5° accuracy, providing accurate guidance with respect to the preoperative reduction plan. The cadaver study and retrospective clinical study demonstrated comparable accuracy: ~0.90 Dice coefficient in segmentation, ~3 mm accuracy in reduction planning, and ~2 mm accuracy in 3D-2D registration. CONCLUSION The registration framework demonstrated planning and guidance accuracy within clinical requirements in both simulation and clinical feasibility studies for a broad range of fracture-dislocation patterns. Using routinely acquired preoperative CT and intraoperative fluoroscopy, the framework could improve the accuracy of pelvic fracture reduction, reduce radiation dose, and could integrate well with common clinical workflow without the need for additional navigation systems.
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Affiliation(s)
- R Han
- Department of Biomedical Engineering, The Johns Hopkins University, BaltimoreMD, United States
| | - A Uneri
- Department of Biomedical Engineering, The Johns Hopkins University, BaltimoreMD, United States
| | - R C Vijayan
- Department of Biomedical Engineering, The Johns Hopkins University, BaltimoreMD, United States
| | - P Wu
- Department of Biomedical Engineering, The Johns Hopkins University, BaltimoreMD, United States
| | - P Vagdargi
- Department of Computer Science, The Johns Hopkins University, BaltimoreMD, United States
| | - N Sheth
- Department of Biomedical Engineering, The Johns Hopkins University, BaltimoreMD, United States
| | - S Vogt
- Siemens Healthineers, ErlangenGermany
| | | | - G M Osgood
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, BaltimoreMD, United States
| | - J H Siewerdsen
- Department of Biomedical Engineering, The Johns Hopkins University, BaltimoreMD, United States.
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16
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Fürnstahl P, Casari FA, Ackermann J, Marcon M, Leunig M, Ganz R. Computer-assisted femoral head reduction osteotomies: an approach for anatomic reconstruction of severely deformed Legg-Calvé-Perthes hips. A pilot study of six patients. BMC Musculoskelet Disord 2020; 21:759. [PMID: 33208124 PMCID: PMC7677844 DOI: 10.1186/s12891-020-03789-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Legg-Calvé-Perthes (LCP) is a common orthopedic childhood disease that causes a deformity of the femoral head and to an adaptive deformity of the acetabulum. The altered joint biomechanics can result in early joint degeneration that requires total hip arthroplasty. In 2002, Ganz et al. introduced the femoral head reduction osteotomy (FHRO) as a direct joint-preserving treatment. The procedure remains one of the most challenging in hip surgery. Computer-based 3D preoperative planning and patient-specific navigation instruments have been successfully used to reduce technical complexity in other anatomies. The purpose of this study was to report the first results in the treatment of 6 patients to investigate whether our approach is feasible and safe. METHODS In this retrospective pilot study, 6 LCP patients were treated with FHRO in multiple centers between May 2017 and June 2019. Based on patient-specific 3D-models of the hips, the surgeries were simulated in a step-wise fashion. Patient-specific instruments tailored for FHRO were designed, 3D-printed and used in the surgeries for navigating the osteotomies. The results were assessed radiographically [diameter index, sphericity index, Stulberg classification, extrusion index, LCE-, Tönnis-, CCD-angle and Shenton line] and the time and costs were recorded. Radiologic values were tested for normal distribution using the Shapiro-Wilk test and for significance using Wilcoxon signed-rank test. RESULTS The sphericity index improved postoperatively by 20% (p = 0.028). The postoperative diameter of the femoral head differed by only 1.8% (p = 0.043) from the contralateral side and Stulberg grading improved from poor coxarthrosis outcome to good outcome (p = 0.026). All patients underwent acetabular reorientation by periacetabular osteotomy. The average time (in minutes) for preliminary analysis, computer simulation and patient-specific instrument design was 63 (±48), 156 (±64) and 105 (±68.5), respectively. CONCLUSION The clinical feasibility of our approach to FHRO has been demonstrated. The results showed significant improvement compared to the preoperative situation. All operations were performed by experienced surgeons; nevertheless, three complications occurred, showing that FHRO remains one of the most complex hip surgeries even with computer assistance. However, none of the complications were directly related to the simulation or the navigation technique.
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Affiliation(s)
- P. Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - F. A. Casari
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
| | - J. Ackermann
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Institute for Orthopedic Biomechanics, ETH Zurich, Zurich, Switzerland
| | - M. Marcon
- Radiology Department, Balgrist University Hospital, Zurich, Switzerland
| | - M. Leunig
- Schulthess Clinic, Zurich, Switzerland
| | - R. Ganz
- Faculty of Medicine, University of Berne, Berne, Switzerland
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17
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Carrillo F, Suter S, Casari FA, Sutter R, Nagy L, Snedeker JG, Fürnstahl P. Digitalization of the IOM: A comprehensive cadaveric study for obtaining three-dimensional models and morphological properties of the forearm's interosseous membrane. Sci Rep 2020; 10:6401. [PMID: 32286490 PMCID: PMC7156465 DOI: 10.1038/s41598-020-63436-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/31/2020] [Indexed: 11/15/2022] Open
Abstract
State-of-the-art of preoperative planning for forearm orthopaedic surgeries is currently limited to simple bone procedures. The increasing interest of clinicians for more comprehensive analysis of complex pathologies often requires dynamic models, able to include the soft tissue influence into the preoperative process. Previous studies have shown that the interosseous membrane (IOM) influences forearm motion and stability, but due to the lack of morphological and biomechanical data, existing simulation models of the IOM are either too simple or clinically unreliable. This work aims to address this problematic by generating 3D morphological and tensile properties of the individual IOM structures. First, micro- and standard-CT acquisitions were performed on five fresh-frozen annotated cadaveric forearms for the generation of 3D models of the radius, ulna and each of the individual ligaments of the IOM. Afterwards, novel 3D methods were developed for the measurement of common morphological features, which were validated against established optical ex-vivo measurements. Finally, we investigated the individual tensile properties of each IOM ligament. The generated 3D morphological features can provide the basis for the future development of functional planning simulation of the forearm.
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Affiliation(s)
- Fabio Carrillo
- Research in Orthopedic Computer Science, Balgrist University Hospital, CH-8008, Zurich, Switzerland. .,Laboratory for Orthopaedic Biomechanics, Institute for Biomechanics, ETH Zurich, CH-8008, Zurich, Switzerland.
| | - Simon Suter
- Research in Orthopedic Computer Science, Balgrist University Hospital, CH-8008, Zurich, Switzerland
| | - Fabio A Casari
- Research in Orthopedic Computer Science, Balgrist University Hospital, CH-8008, Zurich, Switzerland.,Department of Orthopaedics, Balgrist University Hospital, CH-8008, Zurich, Switzerland
| | - Reto Sutter
- Radiology, Balgrist University Hospital, CH-8008, Zurich, Switzerland
| | - Ladislav Nagy
- Research in Orthopedic Computer Science, Balgrist University Hospital, CH-8008, Zurich, Switzerland.,Department of Orthopaedics, Balgrist University Hospital, CH-8008, Zurich, Switzerland
| | - Jess G Snedeker
- Laboratory for Orthopaedic Biomechanics, Institute for Biomechanics, ETH Zurich, CH-8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science, Balgrist University Hospital, CH-8008, Zurich, Switzerland
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18
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Fucentese SF, Meier P, Jud L, Köchli GL, Aichmair A, Vlachopoulos L, Fürnstahl P. Accuracy of 3D-planned patient specific instrumentation in high tibial open wedge valgisation osteotomy. J Exp Orthop 2020; 7:7. [PMID: 32107659 PMCID: PMC7046844 DOI: 10.1186/s40634-020-00224-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/10/2020] [Indexed: 11/11/2022] Open
Abstract
Purpose High tibial osteotomy (HTO) is an effective treatment option in early osteoarthritis. However, preoperative planning and surgical execution can be challenging. Computer assisted three-dimensional (3D) planning and patient-specific instruments (PSI) might be helpful tools in achieving successful outcomes. Goal of this study was to assess the accuracy of HTO using PSI. Methods All medial open wedge PSI-HTO between 2014 and 2016 were reviewed. Using pre- and postoperative radiographs, hip-knee-ankle angle (HKA) and posterior tibial slope (PTS) were determined two-dimensionally (2D) to calculate 2D accuracy. Using postoperative CT-data, 3D surface models of the tibias were reconstructed and superimposed with the planning to calculate 3D accuracy. Results Twenty-three patients could be included. A mean correction of HKA of 9.7° ± 2.6° was planned. Postoperative assessment of HKA correction showed a mean correction of 8.9° ± 3.2°, resulting in a 2D accuracy for HKA correction of 0.8° ± 1.5°. The postoperative PTS changed by 1.7° ± 2.2°. 3D accuracy showed average 3D rotational differences of − 0.1° ± 2.3° in coronal plane, − 0.2° ± 2.3° in transversal plane, and 1.3° ± 2.1° in sagittal plane, whereby 3D translational differences were calculated as 0.1 mm ± 1.3 mm in coronal plane, − 0.1 ± 0.6 mm in transversal plane, and − 0.1 ± 0.6 mm in sagittal plane. Conclusion The use of PSI in HTO results in accurate correction of mechanical leg axis. In contrast to the known problem of unintended PTS changes in conventional HTO, just slight changes of PTS could be observed using PSI. The use of PSI in HTO might be preferable to obtain desired correction of HKA and to maintain PTS.
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Affiliation(s)
- Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Patrick Meier
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Lukas Jud
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland.
| | - Gian-Luca Köchli
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Alexander Aichmair
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Philipp Fürnstahl
- Computer Assisted Research and Development Group (CARD), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Hirsiger S, Schweizer A, Miyake J, Nagy L, Fürnstahl P. Corrective Osteotomies of Phalangeal and Metacarpal Malunions Using Patient-Specific Guides: CT-Based Evaluation of the Reduction Accuracy. Hand (N Y) 2018; 13:627-636. [PMID: 28895433 PMCID: PMC6300182 DOI: 10.1177/1558944717726135] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical planning of corrective osteotomies is traditionally based on conventional radiographs and clinical findings. In the past 10 years, 3-dimensional (3D) preoperative planning approaches with patient-specific guides have been developed. However, the application of this technology to posttraumatic deformities of the metacarpals and phalangeal bones has not yet been investigated. Our goal was to evaluate the feasibility of the surgical application to the latter and to evaluate the extent and precision of correction. METHODS We present results of 6 patients (8 osteotomies) treated with phalangeal or metacarpal corrective osteotomy. Deformities were located in the third ray in 1, fourth ray in 3, and fifth ray in 4 cases. Six malunited metacarpal bones (1 intra-articular) and 2 deformed proximal phalanges were treated. Computer-based 3D preoperative planning using the contralateral hand as a template allowed the production of 3D-printed patient-specific guides that were used intraoperatively for navigation. The precision of the reduction was assessed using pre- and postoperative computed tomography by comparing the postoperative bone model with the preoperatively simulated osteotomy. Range of motion and grip strength were documented pre- and postoperatively. RESULTS The mean follow-up time was 6 months (range: 5-11 months). Rotational deformity was reduced from a mean of 10.0° (range: 7.2°-19.3°) preoperatively to 2.3° (range: 0.7°-3.7°) postoperatively, and translational incongruency decreased from a mean of 1.4 mm (range: 0.7-2.8 mm) to 0.4 mm (range: 0.1-0.9 mm). CONCLUSION Preliminary results indicate that a precise reduction for corrective osteotomies of metacarpal and phalangeal bones can be achieved by using 3D planning and patient-specific guides.
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Affiliation(s)
| | | | | | | | - Philipp Fürnstahl
- University of Zurich, Switzerland,Philipp Fürnstahl, Department of
Orthopedics, University Hospital Balgrist, University of Zurich, Forchstrasse
340, Zürich 8008, Switzerland.
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Roner S, Vlachopoulos L, Nagy L, Schweizer A, Fürnstahl P. Accuracy and Early Clinical Outcome of 3-Dimensional Planned and Guided Single-Cut Osteotomies of Malunited Forearm Bones. J Hand Surg Am 2017; 42:1031.e1-1031.e8. [PMID: 28888571 DOI: 10.1016/j.jhsa.2017.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the reduction accuracy of 3-dimensional planned single-cut osteotomies (SCOTs) of the forearm that were performed using patient-specific guides. METHODS A retrospective analysis of SCOTs performed between 2012 and 2014 was performed. Ten patients (age, 15-59 years) with 6 malunions of the ulna and 6 malunions of the radius were identified. The reduction accuracy was assessed by comparing the 3-dimensional preoperative plan of each osteotomy with the superimposed bone model extracted from postoperative computed tomography data. The difference was assessed by 3-dimensional angle and in all 6 degrees of freedom (3 translations, 3 rotations) with respect to an anatomical coordinate system. Wrist range of motion and grip strength was assessed after a mean of 16.7 months and compared with the preoperative measurements. RESULTS On average, the 12 SCOTs demonstrated excellent accuracy of the reduction with respect to rotation (ie, pronation/supination, 4.9°; flexion/extension, 1.7°; ulnar/radial angulation, 2.0°) and translation (ie, proximal/distal, 0.8 mm; radial/ulnar, 0.8 mm; dorsal/palmar, 0.8 mm). A mean residual 3-dimensional angle of 5.8° (SD, 3.6°) was measured after surgery. All 6 patients operated on for reasons of a reduced range of motion demonstrated improved symptoms and increased movement (from 20° to 80°). In the patients with unstable/painful distal radioulnar joint, 3 were totally free of complaints and 1 patient showed residual pain during sports. CONCLUSIONS A SCOT combined with patient-specific guides is an accurate and reliable technique to restore normal anatomy in multiplanar deformities of the forearm. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Simon Roner
- Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Lazaros Vlachopoulos
- Computer Assisted Research and Development Team, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ladislav Nagy
- Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andreas Schweizer
- Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Computer Assisted Research and Development Team, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Interactive segmentation in MRI for orthopedic surgery planning: bone tissue. Int J Comput Assist Radiol Surg 2017; 12:1031-1039. [PMID: 28342107 DOI: 10.1007/s11548-017-1570-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Planning orthopedic surgeries is commonly performed in computed tomography (CT) images due to the higher contrast of bony structure. However, soft tissues such as muscles and ligaments that may determine the functional outcome of a procedure are not easy to identify in CT, for which fast and accurate segmentation in MRI would be desirable. To be usable in daily practice, such method should provide convenient means of interaction for modifications and corrections, e.g., during perusal by the surgeon or the planning physician for quality control. METHODS We propose an interactive segmentation framework for MR images and evaluate the outcome for segmentation of bones. We use a random forest classification and a random walker-based spatial regularization. The latter enables the incorporation of user input as well as enforcing a single connected anatomical structures, thanks to which a selective sampling strategy is proposed to substantially improve the supervised learning performance. RESULTS We evaluated our segmentation framework on 10 patient humerus MRI as well as 4 high-resolution MRI from volunteers. Interactive humerus segmentations for patients took on average 150 s with over 3.5 times time-gain compared to manual segmentations, with accuracies comparable (converging) to that of much longer interactions. For high-resolution data, a novel multi-resolution random walker strategy further reduced the run time over 20 times of the manual segmentation, allowing for a feasible interactive segmentation framework. CONCLUSIONS We present a segmentation framework that allows iterative corrections leading to substantial speed gains in bone annotation in MRI. This will allow us to pursue semi-automatic segmentations of other musculoskeletal anatomy first in a user-in-the-loop manner, where later less user interactions or perhaps only few for quality control will be necessary as our annotation suggestions improve.
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A Time Saver: Optimization Approach for the Fully Automatic 3D Planning of Forearm Osteotomies. LECTURE NOTES IN COMPUTER SCIENCE 2017. [DOI: 10.1007/978-3-319-66185-8_55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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