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

A dual dimensional optimization strategy for automatic osteotomy preoperative planning in congenital radioulnar synostosis

Congenital radioulnar synostosis (CRUS) presents a complex forearm deformity, requiring precise osteotomy planning for anatomical restoration. This study proposes an automatic osteotomy preoperative planning method for forearms with CRUS. Proximal forearm bones are first aligned with the template forearm and then a dual dimensional optimization (DDO) strategy is used to optimize the spatial transformation parameters of the distal fragment. The subsequent optimization aims to maximize the overlap of cross-sections between proximal and distal fragments. Rotational simulations are ultimately conducted to predict postoperative forearm rotational functionality. The DDO strategy effectively restores ideal forearm morphology, with maximum deviations of 1.66 and 2.13 mm for the ulna and radius, respectively. On the coronal, sagittal and transverse planes, the deformity angles of the radius were reduced to 1.35°, 1.39°, 4.83°, respectively, while those of the ulna were reduced to 1.20°, 1.03°, and 8.56°, respectively. Rotation function analysis reveals a noticeable improvement in achievable rotation range compared to plans by senior surgeons. Automated mobilization osteotomy planning, using the DDO strategy, shows potential for individualized CRUS corrective surgery, offering comprehensive and precise preoperative guidance.

Computer aided multiplanar osteotomy using patient specific instrumentation to treat cubitus varus in children

Cubitus varus deformity is a common complication of supracondylar fractures in children. Anatomic correction is the key to obtaining good functional results and avoiding later symptomatic degradation. Different techniques have been described, mainly lateral closing wedge osteotomy. A medial opening wedge osteotomy seems more intuitive, allowing an anatomic reduction, but it is technically challenging. Two-plane radiographs are too simplistic to appreciate the 3D deformity. With medical imaging and image processing advances, three-dimensional (3D) virtual models of a patient's anatomy can be generated. Rapid 3D printing has allowed virtual simulations of surgical corrections to be transferred to real-world applications in the operating room, allowing more precise and accurate surgery with better 3D corrections. 3D computer modeling with the development of customized drilling and cutting guides allows complex medial opening wedge osteotomy for correction of cubitus varus deformity in immature children with best-fit plate synthesis. LEVEL OF EVIDENCE: IV.

The Use of 3-Dimensional Modeling and Printing in Corrective Osteotomies of the Malunited Pediatric Forearm: A Systematic Review and Meta-Analysis

INTRODUCTION

Forearm fractures contribute up to 40% of all pediatric fractures, with ≤39% of conservatively managed fractures resulting in malunion. Surgical management of malunion is challenging as precise calculation of multiplanar correction is required to obtain optimal outcomes. Advances in 3D computer modeling and printing have shown promising results in orthopaedics, reducing surgical time, blood loss, and fluoroscopy. This systematic review and meta-analysis are the first to explore the accuracy and functional outcome of 3D techniques in pediatric diaphyseal forearm malunion correction.

METHODS

A systematic review was carried out according to PRISMA guidelines.

RESULTS

Sixteen studies (44 patients) were included. Average 2D residual deformity was 1.84° (SD=1.68°). The average gain in range of movement (ROM) was 76.08° (SD=41.75°), with a statistically significant difference between osteotomies ≤12 months from injury and >12 months (96.36° vs. 64.91°, P = 0.027). Below a 2D residual deformity of 5.28°, no statistically significant difference on gain of ROM was found, indicating this as a nonconsequential residual deformity (P = 0.778). Multivariate regression analysis showed that 2D residual deformity and time to osteotomy only account for 6.3% gain in ROM, indicating that there are more factors to be researched.

CONCLUSION

This study found superior accuracy of 3D techniques, reporting lower residual deformities than published standard osteotomy data; however, the volume of literature was limited. Larger studies are required to explore additional factors that influence accuracy and ROM, such as 3D residual deformity and the effect of particular 3D printed adjuncts. This will aid clarity in determining superiority and improve cost-effectiveness.

In vitro comparative study of deformation of 3D-printed models using different polylactic acids treated by steam sterilization

INTRODUCTION

3D printing, which is becoming ever more widespread in orthopedic surgery, requires specific materials. Polylactic acid (PLA) is the most widely used in general-purpose 3D printing, but its thermosensitivity can be incompatible with sterilization. Even so, it is easy to use, inexpensive, non-toxic and biodegradable. Controversy surrounds its use. 3D printing of directly sterilizable PLA parts according to surgeons' needs would be highly advantageous, but doubts remain. We therefore performed an in vitro study to determine which PLAs resist steam sterilization regarding deformation.

HYPOTHESIS

The study hypothesis was that, depending on make and shape, 3D-printed PLA parts can retain their properties after steam sterilization.

MATERIAL AND METHODS

We selected 4 makes of PLA and used each to print 4 simple cubes and 4 complex shapes corresponding to cuboid bones. They were subjected to steam sterilization under normal French hospital conditions. The size of the cubes was measured before and after sterilization, using a digital caliper.

RESULTS

Cuboid parts in HT-PLA and PLA-WANAO showed mean deformation of -0.02mm and -0.4mm, respectively after sterilization, the differences being non-significant (p=0.679 and p=0.241, respectively). Cuboid parts in PLA-SUNLU and PLA-G3D showed significant mean deformation: respectively, -1.37mm (p=0.026) and -35.03mm (p>0.001). Cubes in all types of PLA showed significant mean deformation: HT-PLA, -0.61mm (p=0.004); PLA-SUNLU, -2.70mm (p=0.002); PLA-G3D, -28.64mm (p>0.001); and PLA-WANAO, -1.33mm (p=0.010).

DISCUSSION

The study confirmed recent findings that steam sterilization is feasible with certain PLA-printed parts, with deformations less than 1mm, and that choice of PLA is crucial for success. Computer-designed objects (here, cubes) did not resist sterilization without significant deformation. Analysis of resistance to various stresses was not performed, and therefore it cannot be claimed that the process could be used other than for printing anatomic parts. Use of 3D printing in French hospitals is probably a real source of innovation and improvement in care quality; however, a legal framework needs establishing for the use of 3D-printed parts, to ensure patient safety and promote research in this field.

LEVEL OF EVIDENCE

III; prospective in vitro study.

Early Results of 3-Dimensional Planning and Customized Cutting Guides for the Treatment of Severe Madelung Deformity

PURPOSE

Surgical treatment of Madelung deformity can present challenges due to a need for multiplanar correction. Developing customized cutting guides for osteotomies may improve surgical outcomes by enhancing the surgeon's understanding and surgical correction.

METHODS

All patients who underwent forearm osteotomies for Madelung deformity using computed tomography planning with 3-dimensional-printed customized cutting guides were retrospectively reviewed (n = 8). Seven patients underwent a double osteotomy of the radius, and 1 underwent a single osteotomy.

RESULTS

Ulnar tilt was improved in all cases. Correction of deformity was significant on anteroposterior but not on lateral views. The mean preoperative and postoperative radial bow was measured in 2 planes, with an average preoperative bow of 32° (± 21°) on anteroposterior radiographs and 36° (± 17°) on lateral radiographs, and an average bow of 10° (± 6°) on anteroposterior radiographs and 7° (± 6°) on lateral films after surgery. The predicted radial bow was calculated to be 9.1° (± 8°).

CONCLUSIONS

Three-dimensional planning allows predictable deformity correction across multiple but not all parameters. Future studies comparing clinical and radiographic outcomes of guided versus nonguided osteotomies are required to justify the additional expense and preoperative planning efforts.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Three-dimensional-printing-guided preoperative planning of upper and lower extremity pediatric orthopedic surgeries: A systematic review of surgical outcomes

Purpose

Three-dimensional printing has evolved into a cost-effective and accessible tool. In orthopedic surgery, creating patient-specific anatomical models and instrumentation improves visualization and surgical accuracy. In pediatric orthopedics, three-dimensional printing reduces operating time, radiation exposure, and blood loss by enhancing surgical efficacy. This review compares outcomes of three-dimensional printing-assisted surgeries with conventional surgeries for upper and lower extremity pediatric surgeries.

Methods

A complete search of medical literature up to August 2023, using Ovid Medline, EMBASE, Scopus, Web of Science, and Cochrane Library was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Broad search terms included "pediatrics," "orthopedic," and "3D-printing." Eligible studies were assessed for intraoperative time, blood loss, and fluoroscopy exposure.

Results

Out of 3299 initially identified articles, 14 articles met inclusion criteria. These studies included 409 pediatric patients, with ages averaging 9.51 years. The majority were retrospective studies (nine), with four prospective and one experimental study. Studies primarily utilized three-dimensional printing for navigation templates and implants. Results showed significant reductions in operative time, blood loss, and radiation exposure with three-dimensional printing. Complication occurrences were generally lower in three-dimensional printing surgeries, but there was no statistical significance.

Conclusions

Three-dimensional printing is an emerging technology in the field of orthopedics, and it is primarily used for preoperative planning. For pediatric upper and lower extremity surgeries, three-dimensional printing leads to decreased operating room time, decreased intraoperative blood loss, and reduced radiation exposure. Other uses for three-dimensional printing include education, patient communication, the creation of patient-specific instrumentation and implants.

Level of evidence

Level III.

3D pre-operative planning and patient-specific guides for re-directional peri-acetabular osteotomy in children and adolescents

Surgical procedures to correct hip dysplasia associated with subluxation or dislocation of the femoral head are complex. The 3D geometric abnormalities of the acetabulum and proximal femur vary across patients. We, therefore, suggest a patient-specific surgical treatment involving computer-assisted 3D planning of the peri-acetabular osteotomies, taking into account the femoral head position; 3D printing of patient-specific guides for the cuts, repositioning, and fixation; and intra-operative application of the simulated displacements with their fixation. LEVEL OF EVIDENCE: IV.

State of the art review: The pathogenesis and management of Madelung deformity

Madelung deformity remains a fascinating yet unresolved challenge. There is an increasing awareness for early diagnosis by healthcare providers with improvement in diagnostic modalities, however, the exact mechanisms for the development of the deformity have still to be clarified. While some corrective procedures have been described to effectively address an established deformity, the existing literature lacks clear and evidence-based treatment guidelines on how to proceed in daily practice. This review article aims to summarize the current best evidence on this topic, including particular areas of controversy and areas with need for future research.

Office Three-Dimensional Printed Osteotomy Guide for Corrective Osteotomy in Fibrous Dysplasia

Fibrous dysplasia is a benign condition but can lead to severe long-bone deformities. Three-dimensional (3D) printing technology is a rapidly developing field that has now been popularized to aid surgeons in preoperative planning. We report a case of hip deformity in a 21-year-old woman who suffered from fibrous dysplasia and underwent a corrective osteotomy. We utilized open-source 3D computing software for preoperative planning before producing an osteotomy guide to aid in the operation.

Dual Corrective Osteotomy of the Radius and Ulna for Mature Madelung Deformity Using CT-based 3D Simulation: A Case Report

We report a patient with mature Madelung deformity who underwent radial and ulnar corrective osteotomy using three-dimensional (3D) simulation. An osteotomy model was created using the computer-aided design (CAD) software based on the computed tomography (CT) data. After correcting the ulna, the osteotomy angle of the radius was determined using the location of the lunate as a landmark in the 3D plane created by the longitudinal axis of the corrected ulna. Consequently, the ulna was flexed 3° and shortened by 5 mm, and the radius was extended at 36° and ulna deviated at 25° by open wedge osteotomy. The radial inclinations, volar tilt and ulnar variance were 25°, 45° and 5 mm preoperatively, and improved to 22°, 10° and 0 mm after surgery. At the 18-month follow-up, the patient reported no pain even during sports activity. The preoperative 3D simulation enabled precise preoperative planning and accurate correction of the Madelung deformity. Level of Evidence: Level V (Therapeutic).

Medium to long term functional and radiographic outcomes in patients with Madelung's deformity treated by isolated or combined radioulnar osteotomy

INTRODUCTION

Madelung's deformity is a rare congenital condition of the wrist that can cause pain, aesthetic concerns, reduced range of motion and grip strength. Currently, there is no consensus on the optimal age for surgery or whether operative procedures can be isolated or combined depending on the extent of the deformity. The main objective of our study was to analyze the postoperative functional clinical results at a minimum of 3-years follow-up in patients operated on for Madelung's deformity. The secondary objectives were (1) comparison of preoperative and postoperative radiographic parameters, and (2) to assess whether certain preoperative radiographic parameters influence the choice of surgical procedure.

HYPOTHESIS

The surgery offered at our center achieves clinical and radiological result necessary for long-term activities of daily living, and varies according to the severity of the distal radial deformity.

PATIENTS AND METHODS

We carried out a retrospective observational monocentric study including patients operated on between 2004 and 2016. Clinical (VAS, mobility), functional (PRWE score), and radiographic assessments were performed before and after the last follow-up.

RESULTS

The study included 11 patients (12 wrists) with a mean age of 17±7.3 years and a mean follow-up of 8.1 years (4-12.3). The mean VAS was 2.3 (0-6) and the mean PRWE score was 37 (0-108). The mean flexion-extension arc was 134° and that of pronation and supination was 142°. The mean grip strength was 25.8±11.8kg. Four out of 6 radiographic criteria were significantly improved. An isolated radial osteotomy or combined radioulnar osteotomy was performed when the sagittal radial tilt was greater than 30° and protrusion of the lunate greater than 5mm, otherwise below these values, an isolated ulnar osteotomy was performed.

DISCUSSION

Our center offers surgical management of Madelung's deformity by osteotomy which improves the majority of postoperative radiographic parameters and gives satisfactory clinical and radiographic results after a mean follow-up of 8.1 years. The surgery is influenced by the severity of the distal radial deformity, including protrusion of the lunate and sagittal radial tilt.

LEVEL OF EVIDENCE

IV, Retrospective study.

3D accuracy and clinical outcomes of corrective osteotomies with patient-specific instruments in complex upper extremity deformities: an approach for investigation and correlation

Background

Corrective osteotomies of the upper extremities with patient-specific instruments (PSIs) are increasingly used. In this context, the concordance between planning and postoperative 3D radiographs as well as the association between 3D accuracy and clinical outcome has rarely been evaluated. In this pilot study, we aimed to investigate our clinical mid-term outcome and 3D accuracy as well as their possible correlation, including identifying aspects critical to reaching optimal correction results.

Methods

From October 2018 to January 2020, we used PSIs for 12 corrective osteotomies of the upper extremity in 11 bones of 8 patients (congenital or posttraumatic deformities in 2 elbows, 3 forearms, 3 distal radii). In follow-up examination (10–25 months postoperatively), patient satisfaction, grip strength, ROM, VAS, and DASH were evaluated. Three-dimensional radiological accuracy was determined with 3D-reconstructed postoperative CT scans. With the software tool “Part Comparison” of Mimics^® Innovation Suite Software/Materialise, surface differences of pre-planned and postoperative 3D models were compared.

Results

Compared to the preoperative situation pain and function were better at follow-up: The average VAS score significantly decreased from 6.5 ± 4.1 cm preoperatively to 2.3 ± 2.6 cm at the follow-up time point (p = 0.008). The average DASH score significantly improved, from 48.4 ± 30.9 to 27.0 ± 25.2 (p = 0.015). In the part comparison analysis “planned vs postoperative comparison”, significantly more points in percent (= 3D accuracy) were in a −3 mm to 3 mm interval than in the “preoperative vs planned comparison” (87.3 ± 13.8% vs 48.9 ± 16.6%, p = 0.004). After surgery, the maximum deviation value over all cases was 4.5 ± 1.1 mm, and the minimum deviation value was − 4.5 ± 1.2 mm vs preoperatively 12.9 ± 6.2 mm (p = 0.004) and − 7.2 ± 2.1 mm (p = 0.02), respectively. Clinically, in all cases with higher accuracy (> 90%), an improvement of either DASH or VAS or both of > 60% to the preoperative values occurred. There was a significant correlation between accuracy (%) and ΔVAS (p = 0.004). There were no method-related complications.

Conclusions

Our data after PSI-based corrective osteotomy in complex deformities of the upper extremity in a limited number of cases indicate a positive correlation between 3D accuracy and clinical outcomes. Examination of 3D accuracy to analyse sources of error in the hole procedure from initial CT scan to end of surgery even in patients with not fully satisfactory clinical results is required for further development of the method to achieve optimal correction results with nearly 100% congruence between the planned and postoperative 3D bone position.

Trial registration This retrospective study was registered in the Center for Translational & Clinical Research Aachen (CTC-A) with the number 20-514 on November 20, 2021