Corrective Osteotomy for Malunited Diaphyseal Forearm Fractures Using Preoperative 3-Dimensional Planning and Patient-Specific Surgical Guides and Implants

Functional outcome of 2-D- and 3-D-guided corrective forearm osteotomies: a systematic review

We performed a systematic review to compare conventional (2-D) versus 3-D-guided corrective osteotomies regarding intraoperative results, patient-reported outcome measures, range of motion, incidence of complications and pain score. PubMed (MEDLINE), Embase and Cochrane CENTRAL were searched, and 53 articles were included, reporting 1257 patients undergoing forearm corrective osteotomies between 2010 and 2022. 3-D-guided surgery resulted in a greater improvement in median Disabilities of the Arm, Shoulder and Hand (DASH) score (28, SD 7 vs. 35, SD 5) and fewer complications (12% vs. 6%). Pain scores and range of motion were similar between 3-D-guided and conventional surgery. 3-D-guided corrective osteotomy surgery appears to improve patient-reported outcomes and reduce complications compared to conventional methods. However, due to the limited number of comparative studies and the heterogeneity of the studies, a large randomized controlled trial is needed to draw definitive conclusions.Level of evidence: III.

Three-Dimensionally Planned and Printed Patient-Tailored Plates for Corrective Osteotomies of the Distal Radius and Forearm

PURPOSE

We evaluated the 1-year postoperative clinical and patient-reported outcomes in patients who had a 3-dimensional planned corrective osteotomy of their distal radius, radial shaft, or ulnar shaft using a printed, anatomical, patient-tailored plate to determine the feasibility and effectiveness of this methodology.

METHODS

Simulations in computer-assisted preoperative planning of corrective osteotomies resulted in 3-dimensionally printed surgical guides, surgical models, and anatomically customized plates for application at the distal radius and forearm. Patients with malunions of the distal radius or forearm who underwent fixation with the custom-made plates were documented in our registry. Grip strength and range of motion assessments were made before surgery (baseline), as well as at 6 weeks and 3 and 12 months. Additionally, patients rated their wrist-related pain and disability using the Patient-Rated Wrist Evaluation.

RESULTS

Fifteen patients underwent corrective surgery, and the 1-year follow-up data of 14 patients with a median age of 56 years (interquartile range, 24-64 years) were available for analysis. The median baseline Patient-Rated Wrist Evaluation score improved from 47 to 7 after 1 year. The flexion-extension arc of motion of the wrist increased from 90° at baseline to 130° at 1 year and the pronation-supination arc of motion of the wrist increased from 135° to 160° in the same time period. Differences in radiological measurements for palmar and radial inclinations, as well as for ulnar variance between the affected and contralateral wrists, were reduced with the osteotomy. In 1 case, the plate was removed 11 months after the osteotomy. No severe adverse events were reported.

CONCLUSIONS

Three-dimensionally planned and printed patient-tailored plates offer a reliable method for correcting even complex malunions of the distal radius and forearm.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Three cases of posttraumatic wrist problems solved with 3D-printed patient-specific guides

Symptomatic malunion of the wrist is one of the most common posttraumatic wrist problems. This study demonstrates three patients with complex malunions of the wrist who benefited from a corrective osteotomy using preplanned 3D-printed patient-specific guides, by experiencing improvement in their wrist function, grip strength and a reduction in pain.

Pediatric Forearm Malunions

The aim of this article is to review the evaluation and management of pediatric forearm malunions. Acceptable parameters for nonoperative management of pediatric forearm fractures are reviewed, followed by clinical and imaging workups of malunions and decision-making points for treatment. The landscape of available technology for planning and execution of corrective osteotomy is discussed. Several cases of pediatric forearm malunion are presented, along with surgical and functional outcomes. Recommendations are given regarding the authors' preferred approach for management of pediatric forearm malunions.

3D-assisted corrective osteotomies of the distal radius: a comparison of pre-contoured conventional implants versus patient-specific implants

PURPOSE

There is a debate whether corrective osteotomies of the distal radius should be performed using a 3D work-up with pre-contoured conventional implants (i.e., of-the-shelf) or patient-specific implants (i.e., custom-made). This study aims to assess the postoperative accuracy of 3D-assisted correction osteotomy of the distal radius using either implant.

METHODS

Twenty corrective osteotomies of the distal radius were planned using 3D technologies and performed on Thiel embalmed human cadavers. Our workflow consisted of virtual surgical planning and 3D printed guides for osteotomy and repositioning. Subsequently, left radii were fixated with patient-specific implants, and right radii were fixated with pre-contoured conventional implants. The accuracy of the corrections was assessed through measurement of rotation, dorsal and radial angulation and translations with postoperative CT scans in comparison to their preoperative virtual plan.

RESULTS

Twenty corrective osteotomies were executed according to their plan. The median differences between the preoperative plan and postoperative results were 2.6° (IQR: 1.6-3.9°) for rotation, 1.4° (IQR: 0.6-2.9°) for dorsal angulation, 4.7° (IQR: 2.9-5.7°) for radial angulation, and 2.4 mm (IQR: 1.3-2.9 mm) for translation of the distal radius, thus sufficient for application in clinical practice. There was no significant difference in accuracy of correction when comparing pre-contoured conventional implants with patient-specific implants.

CONCLUSION

3D-assisted corrective osteotomy of the distal radius with either pre-contoured conventional implants or patient-specific implants results in accurate corrections. The choice of implant type should not solely depend on accuracy of the correction, but also be based on other considerations like the availability of resources and the preoperative assessment of implant fitting.

Vascularized fibular flap and custom-made synthesis in post-traumatic ulnar diaphyseal pseudarthrosis: a case report

BACKGROUND

Although isolated fractures of the ulnar shaft are considered common and relatively benign injuries, numerous complications can arise especially in the context of suboptimal care pathways. For pediatric patients, however, there is no single indication of the surgical approach. In the context of the management of these complications, it is known that the vascularized fibular graft has numerous advantages and indications in the treatment of recurrent pseudarthrosis. However, in revision surgery the frequent occurrence of anatomical subversions requires the use of fixation means adapted to the individual patient. We present a clinical case of an adult patient suffering from post-traumatic ulnar pseudarthrosis treated with autologous vascularized fibula grafts and 3D-planned custom-made plate.

CASE PRESENTATION

A 38-year-old Ivorian woman came to our attention with a painful nonunion of the ulnar shaft and significant dysmorphism of the left forearm, with shortening and flexion of the limb as an outcome of unspecified road trauma in childhood. No alterations of the nerve compartment were reported. As far as detectable, she had undergone autologous bone grafting and implantation of questionable synthetic means, without acute treatment. Since we evaluated the patient (2012), we have performed two debridement surgeries, associated with autologous avascular bone graft from the iliac crest and plate fixation (2012 and 2014). In both cases, rupture of the fixation media was observed. In 2021, the pseudarthrosis was treated with a vascularized fibular bone graft. The subverted radius and ulna anatomy and poor bone quality required patient-specific reconstruction of the pseudarthrosic ulna from a 3D scan and the production of custom-made plate and screws, supported by the creation of special guides for drilling and by optimizing the positioning of screws with preoperative digital models. In the postoperative period, regular follow-up visits with X-rays evaluations were performed at 1, 3 and 6 months after surgery. No inflammatory reactions or local rejection were found. The fibula graft healed at the proximal ulnar junction six months after the operation while it took eight months to heal at the distal junction. Functionally, we observed a pain reduction and a range-of-motion preservation.

CONCLUSIONS

The multiple failures of diaphyseal reconstruction with avascular bone grafts have forced the indication to the vascularized fibular flap. This case is a unique experience but we believe that the association between vascularized bone graft and the potential for customization through 3D planning represents a valid surgical potentiality in complex cases of post-traumatic reconstruction.

Clinical Applications of Three-Dimensional Printing in Upper Extremity Surgery: A Systematic Review

Three-dimensional printing for medical applications in surgery of the upper extremity has gained in popularity as reflected by the increasing number of publications. This systematic review aims to provide an overview of the clinical use of 3D printing in upper extremity surgery.

METHODS

We searched the databases PubMed and Web of Science for clinical studies that described clinical application of 3D printing for upper extremity surgery including trauma and malformations. We evaluated study characteristics, clinical entity, type of clinical application, concerned anatomical structures, reported outcomes, and evidence level.

RESULTS

We finally included 51 publications with a total of 355 patients, of which 12 were clinical studies (evidence level II/III) and 39 case series (evidence level IV/V). The types of clinical applications were for intraoperative templates (33% of a total of 51 studies), body implants (29%), preoperative planning (27%), prostheses (15%), and orthoses (1%). Over two third of studies were linked to trauma-related injuries (67%).

CONCLUSION

The clinical application of 3D printing in upper extremity surgery offers great potential for personalized approaches to aid in individualized perioperative management, improvement of function, and ultimately help to benefit certain aspects in the quality of life.

Accuracy of 3D Corrective Osteotomy for Pediatric Malunited Both-Bone Forearm Fractures

Re-displacement of a pediatric diaphyseal forearm fracture can lead to a malunion with symptomatic impairment in forearm rotation, which may require a corrective osteotomy. Corrective osteotomy with two-dimensional (2D) radiographic planning for malunited pediatric forearm fractures can be a complex procedure due to multiplanar deformities. Three-dimensional (3D) corrective osteotomy can aid the surgeon in planning and obtaining a more accurate correction and better forearm rotation. This prospective study aimed to assess the accuracy of correction after 3D corrective osteotomy for pediatric forearm malunion and if anatomic correction influences the functional outcome. Our primary outcome measures were the residual maximum deformity angle (MDA) and malrotation after 3D corrective osteotomy. Post-operative MDA > 5° or residual malrotation > 15° were defined as non-anatomic corrections. Our secondary outcome measure was the gain in pro-supination. Between 2016−2018, fifteen patients underwent 3D corrective osteotomies for pediatric malunited diaphyseal both-bone fractures. Three-dimensional corrective osteotomies provided anatomic correction in 10 out of 15 patients. Anatomic corrections resulted in a greater gain in pro-supination than non-anatomic corrections: 70° versus 46° (p = 0.04, ANOVA). Residual malrotation of the radius was associated with inferior gain in pro-supination (p = 0.03, multi-variate linear regression). Three-dimensional corrective osteotomy for pediatric forearm malunion reliably provided an accurate correction, which led to a close-to-normal forearm rotation. Non-anatomic correction, especially residual malrotation of the radius, leads to inferior functional outcomes.

3D planning and patient-specific surgical guides in forearm osteotomy in children: Radiographic accuracy and clinical morbidity

INTRODUCTION

Three-dimensional (3D) planning and patient-specific surgical guides are increasingly used in the treatment of skeletal deformities. The present study hypothesis was that they are reliable in forearm osteotomy in children, with low morbidity.

MATERIAL AND METHODS

Twenty-there children with one or several osteotomies to correct forearm deformities were retrospectively included: 9 (20 osteotomies) with surgical guide (G+), and 14 (28 osteotomies) without (G-). Etiologies comprised 8 cases of Madelung disease (3G+, 5G-) and 15 of post-traumatic malunion (6G+, 9G-). Mean age at surgery was 14.8±1.9 years. The patient-specific 3D-printed polyamide guides were produced from 3D virtual models based on 3D CT reconstruction. Mean follow-up was 22.1±13.6 months.

RESULTS

Mean correction error was 5.3°±4.1 and 4.2°±4.1 in the frontal and sagittal planes respectively in G+ (p=0.6). Surgery time was significantly shorter in G+, by a mean 42min (p=0.02). Mean total radiation dose (preoperative CT+intraoperative fluoroscopy) was significantly higher in G+ (p<0.0001). Complications rates were similar between groups. Improvement in PRWE score was significantly greater in G+.

CONCLUSION

The present preliminary results were encouraging. 3D planning and patient-specific surgical guides can be used in the treatment of forearm deformity in children.

LEVEL OF EVIDENCE

III; retrospective cohort study.

Preoperative Three-Dimensional Simulation of Osteotomy for Correction of Malunion of Both Bones of Forearm: A Case Report

Corrective osteotomy of malunion of both forearm bones is a challenging procedure because it needs accurate angular and rotational correction of both bones. Recent advances in three-dimensional (3D) printing techniques have shown promising results in the correction of complex deformities. We report a patient with malunion of both bones of the forearm in whom we determined site and degree of correction required based on the computed tomography images of the affected side and mirrored images of the contralateral healthy side. We then created 3D printed sawbones and simulated osteotomy to confirm stable dynamic forearm rotation. This method enabled satisfactory restoration of anatomical and functional outcomes. Preoperative dynamic motion simulation using 3D printed anatomic bone model is helpful for complex corrective osteotomy of forearm fracture malunion.

Level of Evidence: Level V (Therapeutic)

Malunion of Pediatric Forearm Shaft Fractures: Management Principles and Techniques

PURPOSE OF REVIEW

Clinically significant malunion of forearm diaphyseal fractures is an uncommon but potentially disabling condition amongst children and adolescents. We present the preoperative evaluation, including imaging, and discuss surgical indications and contemporary approaches to manage such patients, including an illustrative case.

RECENT FINDINGS

While advances in three-dimensional (3D) simulation, modeling, and patient-specific instrumentation have expanded the surgical armamentarium, their impact on long-term outcomes compared to traditional methods remains unknown. Successful outcome following surgical correction of malunion following a both-bone forearm fracture can be achieved with careful patient selection, appropriate indications, and a well-planned surgical execution.

In-hospital production of 3D-printed casts for non-displaced wrist and hand fractures

Objectives: To examine the clinical feasibility and results of a multidisciplinary workflow, employing rapid three-dimensional (3D) scanning and modeling software along with a high-speed printer, for in-hospital production of patient-specific 3D-printed casts, for the treatment of non-displaced wrist and hand fractures. Methods: Consenting adult patients admitted to the emergency department (ED) due to wrist or hand fractures between January and February 2021 were prospectively enrolled. The study participants underwent conversion of the standard plaster of Paris cast to a 3D-printed cast one week after the ED visit, and follow-up examinations were performed around two, six, and twelve weeks later. The primary objective was to examine the clinical feasibility in terms of complexity and length of the overall procedure. Secondary outcomes were patient-reported impressions and radiological results. Results: Twenty patients (16 males, mean age 37 ± 13.1 years) were included. The entire printing workflow took a mean of 161 ± 8 min. All patients demonstrated clinical improvement and fracture union at final follow-up, with no pressure sores or loss of reduction. Patient-reported comfort and satisfaction rates were excellent. The mean Visual Analog Scale was 0.9 ± 1.1 and 0.6 ± 1, and the mean Disabilities of the Arm, Shoulder, and Hand score was 18.7 ± 9.5 and 7.6 ± 7.6 at 2 and 6 weeks after application of the 3D-printed cast, respectively. Conclusion: The in-hospital workflow was feasible and efficient, with excellent clinical and radiographic results and high patient satisfaction and comfort rates. Our medical center now routinely provides this cast option for non-displaced wrist and hand fractures.

Level of evidence: IV, Therapeutic Study

Clinical applications and prospects of 3D printing guide templates in orthopaedics

Background

With increasing requirements for medical effects, and huge differences among individuals, traditional surgical instruments are difficult to meet the patients' growing medical demands. 3D printing is increasingly mature, which connects to medical services critically as well. The patient specific surgical guide plate provides the condition for precision medicine in orthopaedics.

Methods

In this paper, a systematic review of the orthopedic guide template is presented, where the history of 3D-printing-guided technology, the process of guides, and basic clinical applications of orthopedic guide templates are described. Finally, the limitations of the template and possible future directions are discussed.

Results

The technology of 3D printing surgical templates is increasingly mature, standard, and intelligent. With the help of guide templates, the surgeon can easily determine the direction and depth of the screw path, and choose the angle and range of osteotomy, increasing the precision, safety, and reliability of the procedure in various types of surgeries. It simplifies the difficult surgical steps and accelerates the growth of young and mid-career physicians. But some problems such as cost, materials, and equipment limit its development.

Conclusions

In different fields of orthopedics, the use of guide templates can significantly improve surgical accuracy, shorten the surgical time, and reduce intraoperative bleeding and radiation. With the development of 3D printing, the guide template will be standardized and simplified from design to production and use. 3D printing guides will be further sublimated in the application of orthopedics and better serve the patients.

The translational potential of this paper

Precision, intelligence, and individuation are the future development direction of orthopedics. It is more and more popular as the price of printers falls and materials are developed. In addition, the technology of meta-universe, digital twin, and artificial intelligence have made revolutionary effects on template guides. We aim to summarize recent developments and applications of 3D printing guide templates for engineers and surgeons to develop more accurate and efficient templates.

A novel 3D-printed patient-specific instrument based on "H-point" for medial opening wedge high tibial osteotomy: a cadaver study

BACKGROUND

Opening wedge high tibial osteotomy (OWHTO) is an effective surgical treatment for knee osteoarthritis. This study aimed to explore the feasibility and accuracy of a novel 3D-printed patient-specific instrument (PSI) based on "H-point" for medial OWHTO in a prospective cadaver study.

METHODS

Twenty-six fresh-frozen lower limbs were collected and randomly divided into two groups: PSI group treated with 3D virtual preoperative planning and a novel 3D-printed PSI; control group with the standard technique. 3D models were reversely reconstructed for preoperative surgical planning, guide plate design, and simulated osteotomy. Anatomic features of "H-point," surgical time, fluoroscopic dose, correction accuracy including tibiofemoral angle (FTA) and posterior tibial slope (TS) angle were measured.

RESULTS

First, H-point was always described as a bony bulge in the posteromedial to the proximal tibia and had a relatively constant relationship with the osteotomy site. Second, the absolute correction error of mFTA and TS were significantly smaller in the PSI group. The effective rate of TS in the PSI group was more concentrated with absolute correction error within 1° and within 2° for 53.3% and 93.3%, compared to 9.1% and 45.5% in the control group. The total operation time, positioning osteotomy time, distraction correction time and fluoroscopy dose in the PSI group were significantly less than those in the control group.

CONCLUSIONS

The novel 3D-printed PSI based on H-point is feasibility and accuracy with advantages in terms of TS, surgery time and radiation dose for OWHTO.

Outcomes of 3-D corrective osteotomies for paediatric malunited both-bone forearm fractures

Closed treatment of paediatric diaphyseal forearm fractures carries the risk of re-displacement, which can lead to symptomatic malunions. This is because growth will not correct angulation deformity as it does in metaphyseal fractures. The purpose of this prospective cohort study was to evaluate the outcomes after 3-D-planned corrective osteotomy with patient-specific surgical guides for paediatric malunited forearm fractures causing impaired pro-supination. Our primary outcome measure was the gain in pro-supination at 12 months follow-up. Fifteen patients with a mean age at trauma of 9.6 years and time until osteotomy of 5.9 years were included. Preoperatively, patients displayed a mean pro-supination of 67° corresponding to 44% of the contralateral forearm. At final follow-up, this improved to 128°, achieving 85% of the contralateral side. Multivariate linear regression analysis revealed that predictors of greater functional gain after 3-D corrective osteotomy are severe preoperative impairment in pro-supination, shorter interval until 3-D corrective osteotomy and greater angulation of the radius.Level of evidence: III.

Three-dimensional printing in paediatric orthopaedic surgery

Three-dimensional (3D) printing is a rapidly evolving and promising field to improve outcomes of orthopaedic surgery. The use of patient-specific 3D-printed models is specifically interesting in paediatric orthopaedic surgery, as limb deformity corrections often require an individual 3D treatment. In this editorial, various operative applications of 3D printing in paediatric orthopaedic surgery are discussed. The technical aspects and the imaging acquisition with computed tomography and magnetic resonance imaging are outlined. Next, there is a focus on the intraoperative applications of 3D printing during paediatric orthopaedic surgical procedures. An overview of various upper and lower limb deformities in paediatrics is given, in which 3D printing is already implemented, including post-traumatic forearm corrections and proximal femoral osteotomies. The use of patient-specific instrumentation (PSI) or guiding templates during the surgical procedure shows to be promising in reducing operation time, intraoperative haemorrhage and radiation exposure. Moreover, 3D-printed models for the use of PSI or patient-specific navigation templates are promising in improving the accuracy of complex limb deformity surgery in children. Lastly, the future of 3D printing in paediatric orthopaedics extends beyond the intraoperative applications; various other medical applications include 3D casting and prosthetic limb replacement. In conclusion, 3D printing opportunities are numerous, and the fast developments are exciting, but more evidence is required to prove its superiority over conventional paediatric orthopaedic surgery.

Feasibility and 3D Planning of a Novel Patient-Specific Instrumentation Technique in Medial Opening-Wedge High Tibial Osteotomy

A novel approach for opening-wedge high tibial osteotomy (OWHTO) with patient-specific instrumentation (PSI) was evaluated for its safety, feasibility, and accuracy. Next, the mechanical medial proximal tibial angle (mMPTA) was assessed as a potential planning angle by investigating the relation with the mechanical femorotibial angle (mFTA). Ten OWHTO cases were 3D planned using the mMPTA and operated with a customized 3D-printed wedge and cast which resembled the intended osteotomy opening. Patients were closely monitored for intraoperative and postoperative complications up to 1 year after surgery. Radiological assessment was conducted on full leg standing radiographs and supine lower limb computed tomography-scans preoperatively and 3 months after surgery. No intraoperative complications or logistical issues during PSI processing were observed. Absolute accuracy outcomes showed a correction error of 1.3° ± 1.1 mMPTA and 0.9° ± 0.6 mFTA with all osteotomies falling in (-2°; + 2°) mFTA around the target. The mMPTA and mFTA were found to have a strong correlation in both 3D (r = 0.842, p = 0.002) and 2D (r = 0.766, p = 0.01) imaging for effective correction. The study confirmed the development of a safe and feasible PSI technique in OWHTO with excellent accuracy outcomes. The strong correlation between the mMPTA and mFTA indicated that soft tissue changes after OWHTO are of minor significance to the final alignment in ligament-stable patients. Finally, the mMPTA was found to be a reliable planning angle in 3D software for obtaining the intended lower limb realignment and its use can therefore be recommended in modern OWHTO planning.

Three-Dimensional Printing in Hand Surgery

The medical application of 3-dimensional printing technology has evolved in the last decade, with an increasing variety of uses in hand surgery. The ability for patient-specific design, rapid prototyping, and low cost of production of 3-dimensional printed materials has led to this rise in clinical applications, both for common procedures and complex reconstructions. Within hand surgery, 3-dimensional printing can be applied in several broad categories: to construct patient-specific models for preoperative planning, to design orthotics and prosthetics to meet specific patient demands, to create patient-specific aids for intraoperative use, to generate patient-specific hardware and prostheses for implantation, and for applications for trainee education.

Morphological symmetry of the radius and ulna-Can contralateral forearm bones utilize as a reliable template for the opposite side?

The most important precondition for correction of the affected forearm using data from the contralateral side is that the left and right bone features must be similar, in order to develop patient-specific instruments (PSIs) and/or utilize computer-assisted orthopedic surgery (CAOS). The forearm has complex anatomical structure, and most people use their dominant hand more than their less dominant hand, sometimes resulting in asymmetry of the upper limbs. The aim of this study is to investigate differences of the bilateral forearm bones through a quantitative comparison of whole bone parameters including length, volume, bowing, and twisting parameters, and regional shape differences of the forearm bones. In total, 132 bilateral 3D radii and ulnae 3D models were obtained from CT images, whole bone parameters and regional shape were analyzed. Statistically significant differences in whole bone parameters were not shown. Regionally, the radius shows asymmetry in the upper section of the central part to the upper section of the distal part. The ulna shows asymmetry in the lower section of the proximal part to the lower section of the central part. Utilizing contralateral side forearm bones to correct the affected side may be feasible despite regional differences in the forearm bones of around 0.5 mm.

Patient-Specific Guided Osteotomy to Correct a Symptomatic Malunion of the Left Forearm

We present a case report of a 12-year old female with a midshaft forearm fracture. Initial conservative treatment with a cast failed, resulting in a malunion. The malunion resulted in functional impairment for which surgery was indicated. A corrective osteotomy was planned using 3D analyses of the preoperative CT-scan. Subsequently, patient-specific guides were printed and used during the procedure to precisely correct the malunion. Three months after surgery, the radiographs showed full consolidation and the patient was pain-free with full range of motion and comparable strength in both forearms. The current case report shows that a corrective osteotomy with patient-specific guides based on preoperative 3D analyses can help surgeons to plan and precisely correct complex malunions resulting in improved functional outcomes.

Clinical, functional and radiological outcomes of the use of fixed angle volar locking plates in corrective distal radius osteotomy for fracture malunion

Background and aim:

Fractures of the distal radius are a common injury and mal-union can occur in those managed non-operatively. This can cause significant functional limitations along with pain. A corrective osteotomy with the use of a volar locking plate aims to restore articular surface congruency and improve outcomes. We present our local experience with clinical, functional and radiological outcomes of corrective osteotomy using a fixed angle volar locking plate and bone graft for management of distal radius mal-union.

Methods:

Retrospective study. All adult patients. Both pre and post operatively clinical range of motion was recorded. Post operative PROMS was measure by DASH, MAYO and SF-12 and pain by means of a VAS measured from 0-10. Mean follow up period was at 15 months.

Results:

32 patients underwent the studied procedure. 24F-8F. Mean age: 56. Radiological union of corrective osteotomy: 28 (88%) of patients. 4 patients required further operative treatment to achieve corrective union. No other reported complications post-op. Post-operatively flexion improved by 24 and extension 20. Pronation was improved by 24 and supination 22. Pain was improved from an average VAS pre-operative of 5.6 to 1.6 post-operatively. Mean DASH scored improved from 57.8 to 16.2 post-operatively and MAYO 38.5 to 58.6. The mean post-operative SF-12 score was 46.2 from 31.

Conclusions:

In this series of 32 patients (the biggest reported in the literature in our knowledge) a corrective osteotomy with fixed-angle volar locking plate for mal-united distal radius has shown to improve both clinical-radiological and patient reported outcomes and provide good results of the very few complications’ treatments. (www.actabiomedica.it)

Morphometric Evaluation of Detailed Asymmetry for the Proximal Humerus in Korean Population

Computer-assisted orthopedic surgery and patient-specific instruments are widely used in orthopedic fields that utilize contralateral side bone data as a template to restore the affected side bone. The essential precondition for these techniques is that the left and right bone features are similar. Although proximal humerus fracture accounts for 4% to 8% of all fractures, the bilateral asymmetry of the proximal humerus is not fully understood. The aim of this study is to investigate anthropometric differences of the bilateral proximal humerus. One hundred one pairs of Korean humerus CT data from 51 females and 50 males were selected for this research. To investigate bilateral shape differences, we divided the proximal humerus into three regions and the proximal humerus further into five sections in each region. The distance from the centroid to the cortical outline at every 10 degrees was measured in each section. Differences were detected in all regions of the left and right proximal humerus; however, males had a larger number of significant differences than females. Large bilateral differences were measured in the greater tubercle. Nevertheless, using contralateral data as a template for repairing an affected proximal humerus might be possible.

Overview of In-Hospital 3D Printing and Practical Applications in Hand Surgery

Three-dimensional (3D) printing is spreading in hand surgery. There is an increasing number of practical applications like the training of junior hand surgeons, patient education, preoperative planning, and 3D printing of customized casts, customized surgical guides, implants, and prostheses. Some high-quality studies highlight the value for surgeons, but there is still a lack of high-level evidence for improved clinical endpoints and hence actual impact on the patient's outcome. This article provides an overview over the latest applications of 3D printing in hand surgery and practical experience of implementing them into daily clinical routine.

Patient-specific plate for navigation and fixation of the distal radius: a case series

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.

Three-dimensional printing in medicine: a systematic review of pediatric applications

BACKGROUND

Three-dimensional printing (3DP) addresses distinct clinical challenges in pediatric care including: congenital variants, compact anatomy, high procedural risk, and growth over time. We hypothesized that patient-specific applications of 3DP in pediatrics could be categorized into concise, discrete categories of use.

METHODS

Terms related to "three-dimensional printing" and "pediatrics" were searched on PubMed, Scopus, Ovid MEDLINE, Cochrane CENTRAL, and Web of Science. Initial search yielded 2122 unique articles; 139 articles characterizing 508 patients met full inclusion criteria.

RESULTS

Four categories of patient-specific 3DP applications were identified: Teaching of families and medical staff (9.3%); Developing intervention strategies (33.9%); Procedural applications, including subtypes: contour models, guides, splints, and implants (43.0%); and Material manufacturing of shaping devices or prosthetics (14.0%). Procedural comparative studies found 3DP devices to be equivalent or better than conventional methods, with less operating time and fewer complications.

CONCLUSION

Patient-specific applications of Three-Dimensional Printing in Medicine can be elegantly classified into four major categories: Teaching, Developing, Procedures, and Materials, sharing the same TDPM acronym. Understanding this schema is important because it promotes further innovation and increased implementation of these devices to improve pediatric care.

IMPACT

This article classifies the pediatric applications of patient-specific three-dimensional printing. This is a first comprehensive review of patient-specific three-dimensional printing in both pediatric medical and surgical disciplines, incorporating previously described classification schema to create one unifying paradigm. Understanding these applications is important since three-dimensional printing addresses challenges that are uniquely pediatric including compact anatomy, unique congenital variants, greater procedural risk, and growth over time. We identified four classifications of patient-specific use: teaching, developing, procedural, and material uses. By classifying these applications, this review promotes understanding and incorporation of this expanding technology to improve the pediatric care.

The effect of three-dimensional (3D) printing on quantitative and qualitative outcomes in paediatric orthopaedic osteotomies: a systematic review

Three-dimensional (3D) printing technology is increasingly being utilized in various surgical specialities. In paediatric orthopaedics it has been applied in the pre-operative and intra-operative stages, allowing complex deformities to be replicated and patient-specific instrumentation to be used. This systematic review analyses the literature on the effect of 3D printing on paediatric orthopaedic osteotomy outcomes.A systematic review of several databases was conducted according to PRISMA guidelines. Studies evaluating the use of 3D printing technology in orthopaedic osteotomy procedures in children (aged ≤ 16 years) were included. Spinal and bone tumour surgery were excluded. Data extracted included demographics, disease pathology, target bone, type of technology, imaging modality used, qualitative/quantitative outcomes and follow-up. Articles were further categorized as either 'pre-operative' or 'intra-operative' applications of the technology.Twenty-two articles fitting the inclusion criteria were included. The reported studies included 212 patients. There were five articles of level of evidence 3 and 17 level 4.A large variety of outcomes were reported with the most commonly used being operating time, fluoroscopic exposure and intra-operative blood loss.A significant difference in operative time, fluoroscopic exposure, blood loss and angular correction was found in the 'intra-operative' application group. No significant difference was found in the 'pre-operative' category.Despite a relatively low evidence base pool of studies, our aggregate data demonstrate a benefit of 3D printing technology in various deformity correction applications, especially when used in the 'intra-operative' setting. Further research including paediatric-specific core outcomes is required to determine the potential benefit of this novel addition. Cite this article: EFORT Open Rev 2021;6:130-138. DOI: 10.1302/2058-5241.6.200092.

Instability in the Setting of Distal Radius Fractures: Diagnosis, Evaluation, and Treatment

Distal radius fractures with severe displacement or concomitant triangular fibrocartilage complex tears may be accompanied by distal radioulnar joint instability. Clinicians should examine the distal radioulnar joint closely when managing wrist fractures and treat coexisting instability appropriately. Chronic instability from distal radius malunion may require osteotomy or radioulnar ligament reconstruction. With proper management, most patients recover forearm stability and rotational motion after distal radius fracture.

An automatic genetic algorithm framework for the optimization of three-dimensional surgical plans of forearm corrective osteotomies

Three-dimensional (3D) computer-assisted corrective osteotomy has become the state-of-the-art for surgical treatment of complex bone deformities. Despite available technologies, the automatic generation of clinically acceptable, ready-to-use preoperative planning solutions is currently not possible for such pathologies. Multiple contradicting and mutually dependent objectives have to be considered, as well as clinical and technical constraints, which generally require iterative manual adjustments. This leads to unnecessary surgeon efforts and unbearable clinical costs, hindering also the quality of patient treatment due to the reduced number of solutions that can be investigated in a clinically acceptable timeframe. In this paper, we propose an optimization framework for the generation of ready-to-use preoperative planning solutions in a fully automatic fashion. An automatic diagnostic assessment using patient-specific 3D models is performed for 3D malunion quantification and definition of the optimization parameters' range. Afterward, clinical objectives are translated into the optimization module, and controlled through tailored fitness functions based on a weighted and multi-staged optimization approach. The optimization is based on a genetic algorithm capable of solving multi-objective optimization problems with non-linear constraints. The framework outputs a complete preoperative planning solution including position and orientation of the osteotomy plane, transformation to achieve the bone reduction, and position and orientation of the fixation plate and screws. A qualitative validation was performed on 36 consecutive cases of radius osteotomy where solutions generated by the optimization algorithm (OA) were compared against the gold standard solutions generated by experienced surgeons (Gold Standard; GS). Solutions were blinded and presented to 6 readers (4 surgeons, 2 planning engineers), who voted OA solutions to be better in 55% of the time. The quantitative evaluation was based on different error measurements, showing average improvements with respect to the GS from 20% for the reduction alignment and up to 106% for the position of the fixation screws. Notably, our algorithm was able to generate feasible clinical solutions which were not possible to obtain with the current state-of-the-art method.

Seven-year follow-up for malrotation of a radial diaphysis fracture in a child corrected by osteotomy for loss of motion: A case report

A greenstick fracture is an incomplete fracture where the compressive side of the cortex is still intact but plastically deformed. The incidence of poor results following the closed treatment of greenstick fractures in children >10 years of age is seriously underestimated. Therefore, fixing the position of the forearm is important for initial treatment. In cases of greenstick fracture, the possibility of inadequate remodeling of angulated deformities during growth, and in particular, the lack of correction between rotational malalignment and growth when the diaphyseal forearm is involved in the fracture, should be considered. A male, 10-year-old, left hand-dominant, Asian patient fell while playing in the garden and was immediately assessed by an orthopedic doctor at an Emergency Orthopaedic Clinic. Initial examination revealed a deformity of his dominant left forearm and an angulated greenstick fracture of the radius. However, after 3 months, he developed loss of supination of his left forearm and complained of limitation of left forearm supination. Radiography demonstrated a volar angulation of 20°. The patient underwent open reduction, internal fixation and 10° bending with a plate for correction without corrective rotation. At 12 months after injury, the patient did not exhibit pain or limitation of the elbow and wrist. After follow-up for 7 years, the patient was able to perform normal day-to-day activities with no adverse symptoms. The present case indicated that corrective osteotomy is required following the loss of supination after a greenstick fracture of the diaphysis of the radius. The patient of the current study exhibited rotation due to the central band of the interosseous membrane. In the treatment of greenstick fractures, a radius apex angulation of 20° must be corrected via osteotomy due to loss of rotation. The present case indicated that corrective osteotomy of the radius apex alone without rotational correction, in combination with plate bending improved the loss of forearm rotation.

3D printing in hand surgery

While 3D printing in hand surgery is still in its infancy, it offers new avenues in research, teaching, and personalized medicine. For these reasons, some surgeons may want to jump on the bandwagon of this trendy technology. But we cannot forget that its superiority over conventional techniques has not been demonstrated. Surgeons who want to work with 3D printed objects must master their use and the entire manufacturing process, otherwise they risk becoming dependent on engineers and/or medical device companies.

Use of three-dimensional technology for complications of upper limb fracture treatment

In malunion cases, restoration of anatomy is a key factor in obtaining a good functional outcome, but this can be technically very challenging.

Three-dimensional printed bone models can further improve understanding of the malunion pattern.

The use of three-dimensional (3D) computer planning, and the assembly of patient-specific instruments and implants, especially in complex deformities of the upper limb, allow accurate correction while reducing operation time, blood loss volume and radiation exposure during surgery.

One of the major disadvantages of the 3D technique is the additional cost because it requires specific computer software, a dedicated clinical engineer, and a 3D printer.

Further technical developments and clinical investigations are necessary to better define the added value and cost/benefit relationship of 3D in the treatment of complex fractures, non-unions, and malunions.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180074

Complications during the treatment of missed Monteggia fractures with unilateral external fixation: a report on 20 patients in a 10-year period in a tertiary referral center

The treatment of a missed Monteggia (MM) fracture dislocation is still controversial. We describe our initial experience with ulnar osteotomy and progressive correction with unilateral external fixator in MM. We retrospectively evaluated 20 children undergoing ulnar osteotomy and progressive distraction angulation by unilateral external fixator to treat MM. Nine patients had closed reduction, whereas 11 patients had simultaneous open reduction, repair, or reconstruction of the annular ligament and K-wire stabilization of the radiocapitellar joint. Patients were followed for an average of 3 (1-11) years. Three children developed aseptic nonunion and one child had delayed union. A distal level of the osteotomy significantly increased the rate of nonunion or delayed union. At the final follow-up, eight children had complete reduction of the radial head, six children had partial reduction, whereas in six cases, the radial head remained dislocated. The angulation and the level of the osteotomy significantly influenced the relocation, whereas the open reduction had no significant effect on the final position of the radial head. At the final follow-up, the Kim's score averaged 93.25. The flexion-extension arc significantly improved postoperatively, and it was positively correlated with the angulation. The ulnar osteotomy and progressive traction-angulation by unilateral external fixator can achieve satisfactory results in MM, if a meticulous surgical technique is applied; care must be taken regarding the level of osteotomy and the progressive traction-angulation.

Three-Dimensional Corrective Osteotomy for Malunited Fractures of the Upper Extremity Using Patient-Matched Instruments: A Prospective, Multicenter, Open-Label, Single-Arm Trial

BACKGROUND

Medical image processing has facilitated simulation of 3-dimensional (3-D) corrective osteotomy, and 3-D rapid prototyping technology has further enabled the manufacturing of patient-matched surgical guides and implants (patient-matched instruments, or PMIs). However, 3-D corrective osteotomy using these technologies has not been the standard procedure. We aimed to prospectively verify the efficacy and safety of PMIs in corrective osteotomy for deformities of the upper extremity.

METHODS

We enrolled 16 patients with a total of 17 bone deformities in the upper extremity. Eight patients had distal radial malunion; 5, distal humeral malunion; and 3, forearm diaphyseal malunion. All cases underwent 3-D corrective osteotomy with PMIs. The primary end point was the residual maximum deformity angle (MDA), which was calculated from 2 deformity angles-1 on the anteroposterior and 1 on the lateral postoperative radiograph. Secondary end points included the deformity angle on radiographs, 3-D error between the preoperative planning model and the postoperative result, range of motion, grip strength, pain measured with a visual analog scale (VAS), patient satisfaction, and Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The average MDA significantly improved from 25.5° preoperatively to 3.3° at the final follow-up (p < 0.001). The angular deformity was within 5° in all cases, except for 1 with distal radial malunion who had a higher angle on the anteroposterior radiograph. The error between the correction seen on the postoperative 3-D bone model and the planned correction was <1° and <1 mm. Flexion and extension of the wrist and pronation of the forearm of the patients treated for distal radial malunion improved significantly, and pronation improved for those treated for forearm diaphyseal malunion. The average VAS score, grip strength, and DASH score significantly improved as well. Of the 16 patients, 15 were very satisfied or satisfied with the outcomes.

CONCLUSIONS

Corrective osteotomy using PMIs achieved accurate correction and good functional recovery in the upper extremity. Although our study was limited to cases without any deformity on the contralateral side, 3-D corrective osteotomy using PMIs resolved treatment challenges for complex deformities in upper extremities.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of 3 Pediatric Pelvic Osteotomies for Acetabular Dysplasia Using Patient-specific 3D-printed Models

BACKGROUND

Children with developmental dysplasia of the hip may require a pelvic osteotomy to treat acetabular dysplasia. Three osteotomies are commonly performed in these patients (Pemberton, Dega, and San Diego), though comparative studies of each are limited. The purpose of this study was to compare changes in acetabular morphology (acetabular version, volume, and octant coverage angles) created by these 3 osteotomies using matched patient-specific 3D-printed pelvic models.

METHODS

Fourteen patients with developmental dysplasia of the hip and preoperative computed tomography (CT) imaging were retrospectively included. For each patient CT, bone and cartilage tissues were independently segmented, and 3 identical pelvises were 3D-printed using a dual material printer. Bone was printed with rigid material and cartilage with flexible material to simulate the flexibility of the triradiate cartilage and pubic symphysis. Pemberton, Dega, and San Diego acetabular osteotomies were performed on the triplicate set of 3D prints. Acetabular version, volume, and octant coverage angles (posterior, superior-posterior, superior, superior-anterior, and anterior) were determined before and after each mock surgery by morphologic assessment using preoperative and postoperative CT images.

RESULTS

San Diego osteotomy yielded a small increase (+3.34±1.71 degrees) in version, compared with decreases with Pemberton (-5.47±1.54 degrees) and Dega (-8.57±1.21 degrees, P<0.05). Acetabular volume decreased similarly for Pemberton (-13.36%±2.88%), Dega (-19.21%±2.73%), and San Diego (-19.29%±2.44%; P=0.215) osteotomies. San Diego osteotomy tended to have a larger postoperative increase in the posterior regions, and the Dega and Pemberton osteotomies tended to have larger postoperative increases in the anterior coverage regions.

CONCLUSIONS

Quantifiable differences were identified in acetabular octant coverage angles and version between the 3 pelvic osteotomies. San Diego osteotomy increased acetabular coverage posteriorly resulting in acetabular anteversion, whereas Pemberton and Dega had greater superior-anterior coverage resulting in relative acetabular retroversion. This study is the first known to utilize 3D-printed models for comparison of surgical approaches in pediatric pelvic osteotomies.

Implementation of a semiautomatic method to design patient-specific instruments for corrective osteotomy of the radius

PURPOSE

3D-printed patient-specific instruments (PSIs), such as surgical guides and implants, show great promise for accurate navigation in surgical correction of post-traumatic deformities of the distal radius. However, existing costs of computer-aided design and manufacturing process prevent everyday surgical use. In this paper, we propose an innovative semiautomatic methodology to streamline the PSIs design.

METHODS

The new method was implemented as an extension of our existing 3D planning software. It facilitates the design of a regular and smooth implant and a companion guide starting from a user-selected surface on the affected bone. We evaluated the software by designing PSIs starting from preoperative virtual 3D plans of five patients previously treated at our institute for corrective osteotomy. We repeated the design for the same cases also with commercially available software, with and without dedicated customization. We measured design time and tracked user activity during the design process of implants, guides and subsequent modifications.

RESULTS

All the designed shapes were considered valid. Median design times ([Formula: see text]) were reduced for implants (([Formula: see text]) = 2.2 min) and guides (([Formula: see text]) = 1.0 min) compared to the standard (([Formula: see text]) = 13 min and ([Formula: see text]) = 8 min) and the partially customized (([Formula: see text]) = 6.5 min and ([Formula: see text]) = 6.0 min) commercially available alternatives. Mouse and keyboard activities were reduced (median count of strokes and clicks during implant design (([Formula: see text]) = 53, and guide design (([Formula: see text]) = 27) compared to using standard software (([Formula: see text]) = 559 and ([Formula: see text]) = 380) and customized commercial software (([Formula: see text]) = 217 and ([Formula: see text]) = 180).

CONCLUSION

Our software solution efficiently streamlines the design of PSIs for distal radius malunion. It represents a first step in making 3D-printed PSIs technology more accessible.