Plain Lateral Radiographs Research Articles

Effects of the location of both anterior and lateral boundaries of the necrotic lesion on collapse progression in osteonecrosis of the femoral head

BackgroundThe location of the lateral boundary of the necrotic lesion to the weight-bearing portion of the acetabulum (Type classification) is an important factor for collapse in osteonecrosis of the femoral head (ONFH). Recent studies also reported the significance of the location of the anterior boundary of the necrotic lesion on the occurrence of collapse. We aimed to assess the effects of the location of both anterior and lateral boundaries of the necrotic lesion on collapse progression in ONFH. MethodsWe recruited 55 hips with post-collapse ONFH from 48 consecutive patients, who were conservatively followed for more than one year. Using a plain lateral radiograph (Sugioka's lateral view), the location of the anterior boundary of the necrotic lesion to the weight-bearing portion of the acetabulum was classified as follows: Anterior-area I (two hips) occupying the medial one-third or less; Anterior-area II (17 hips) occupying the medial two-thirds or less; and Anterior-area III (36 hips) occupying greater than the medial two-thirds. The amount of femoral head collapse was measured by biplane radiographs at the onset of hip pain and each follow-up period, and Kaplan–Meier survival curves with collapse progression (≥1 mm) as the endpoint were produced. The probability of collapse progression was also assessed by the combination of Anterior-area and Type classifications. ResultsCollapse progression was observed in 38 of the 55 hips (69.0%). The survival rate of hips with Anterior-area III/Type C2 was significantly lower. Among hips with Type B/C1, collapse progression occurred more frequently in hips with Anterior-area III (21 of 24 hips) than in hips with Anterior-area I/II (3 of 17 hips, P < 0.0001). ConclusionsAdding the location of the anterior boundary of the necrotic lesion to Type classification was useful to predict collapse progression especially in hips with Type B/C1.

Radiologic features of radiolucent foreign bodies ingestion in common mynah (Acridotheres tristis).

In mynahs with foreign body ingestion, delayed diagnosis increases the risk of poor outcomes. The aim of this study was to evaluate various radiologic features on plain and contrast radiographs in mynahs for assessing the presence of ingested foreign bodies. In our cross-sectional study, a total of 41 mynahs were included. The diagnosis was made by history, surgery, excision by forceps or excretion in the faeces. Overall, 21 mynahs were considered not to have a foreign body in their gastrointestinal tract. Plain and post-contrast [oral administration of bariumsulphate colloidal suspension of 25% weight/volume (20mg/kg)] lateral and ventrodorsal radiographs from the cervical and coelomic cavity were taken.Different parameters including oesophageal, proventricular, and small intestinal diameters and opacities were assessed. Image evaluation was performed by two national board-certified radiologists blinded to the final diagnoses. The inter- and intra-observer reliabilities of the diagnostic features were significant (p < 0.001). The diagnosis of the foreign body was highly accurate [90.2% (95% CI: 76.9%, 92.3%)] with the sensitivity, specificity, and area under the representative characteristic curve of 90.0%, 90.5%, and 0.93%, respectively for plain radiographs. The size and opacity of the oesophagus, proventriculus, and intestinal loops as well as serosal details were significantly different between mynahs with and without foreign body intake (p < 0.05). Lateral and ventrodorsal plain radiographs are highly reliable for diagnosing the presence of non-opaque obstructing objects in the gastrointestinal tract of mynahs. Attention should be paid to the size and opacity of the oesophagus, extension, and opacity of the proventriculus, segmental opacity of intestinal loops, and decrease in serosal details.

Automated Detection of the Thoracic Ossification of the Posterior Longitudinal Ligament Using Deep Learning and Plain Radiographs.

Ossification of the ligaments progresses slowly in the initial stages, and most patients are unaware of the disease until obvious myelopathy symptoms appear. Consequently, treatment and clinical outcomes are not satisfactory. This study is aimed at developing an automated system for the detection of the thoracic ossification of the posterior longitudinal ligament (OPLL) using deep learning and plain radiography. We retrospectively reviewed the data of 146 patients with thoracic OPLL and 150 control cases without thoracic OPLL. Plain lateral thoracic radiographs were used for object detection, training, and validation. Thereafter, an object detection system was developed, and its accuracy was calculated. The performance of the proposed system was compared with that of two spine surgeons. The accuracy of the proposed object detection model based on plain lateral thoracic radiographs was 83.4%, whereas the accuracies of spine surgeons 1 and 2 were 80.4% and 77.4%, respectively. Our findings indicate that our automated system, which uses a deep learning-based method based on plain radiographs, can accurately detect thoracic OPLL. This system has the potential to improve the diagnostic accuracy of thoracic OPLL.

Clinical Impact and Correlations of Odontoid Parameters Following Multilevel Posterior Cervical Fusion Surgery.

C2 slope (C2S), a cervical parameter mathematically approximated as T1 slope minus cervical lordosis (T1S-CL), predicts functional improvement in cervical deformity patients. Nonetheless, C2S is a positional parameter based only on the horizontal axis. The current study aims to introduce novel odontoid parameters and establish their relationships with patient-reported health-related quality of life (HRQoL). Lateral plain radiographs of 32 adults who underwent multilevel posterior cervical fusion were analyzed. The odontoid parameters included odontoid incidence (OI), C2S, odontoid tilt (OT), and gravity line-C2 distance (GL-C2), while the cervical parameters were the Cobb angle at C0-1, C1-2, C0-2, C2-7, C2-7 sagittal vertical axis (cSVA), T1 slope, and T1S-CL. The range of motion (ROM) of the occipito-atlantoaxial complex was measured in flexion and extension plain radiographs. Scores on the Neck Disability Index (NDI) and visual analogue scale (VAS) for axial neck (VASn) and arm pain were measured. Compared to asymptomatic subjects, patients had larger C2S, cSVA, and T1S-CL, and smaller OT. Preoperatively, OI was significantly correlated with the ROM of C1-2 (r = 0.37, p < 0.05) and C0-2 (r = 0.46, p < 0.01). OT and C2S had significant correlations with the C0-1, C1-2, and C0-2 angles, GL-C2, and T1S-CL. Postoperative NDI scores were significantly correlated with OI (r = -0.40, p < 0.05) and OT (ρ = -0.37, p < 0.05). VASn was significantly correlated with GL-C2 (r = -0.35, p < 0.05). The odontoid parameters were significantly correlated with established cervical parameters and HRQoL measures. OI is a constant parameter representing the individual's compensatory reservoir at the upper cervical spine.

Posterior Protrusion Measures (PPM) as an Innovative Index in Classifying Plain Lateral Radiograph Images of Pertrochanteric Fracture Using the Revised AO Foundation/Orthopaedic Trauma Association (AO/OTA) Classification.

Introduction The absence of a precise fracture classification system that classifies pertrochanteric fractures into either stable or unstable contributes to a burden on healthcare and has several major implications. We propose an innovative graphical index, which we refer to as posterior protrusion measures (PPM), using plain lateral view radiograph images for the revised AO Foundation (Arbeitsgemeinschaft für Osteosynthesesfragen)/Orthopedic Trauma Association (AO/OTA) classification system. This study aims to: (i) introduce the use of PPM for classifying fractures into stable or unstable under the revised AO/OTA classification system and set the threshold numeric value, (ii) elucidate the reproducibility of inter and intra-observer agreement, and investigate the consistency of fracture classification using PPM versus computed tomography (CT) scan images. Materials and methods Out of 146 patients identified from the database, a total of 126 patients were enrolled in the study. Pertrochanteric fractures were classified as either stable or unstable. Three surgeons were assigned for PPM determination. Regarding the demographical data, the chi-square test was used to assess the significance of each parameter on a categorical scale between the two groups. The independent sample t-test or the Mann-Whitney U test was used to compare the two independent groups. Interclass correlation coefficient (ICC) values for continuous variables and kappa values (κ) for categorical variables were calculated to assess inter-observer and intra-observer agreement. Receiver-operating characteristic (ROC) analysis was used to determine optimal cut-off points of PPM to predict consistency between separate fracture classification groups, one using PPM values with a threshold derived from plain radiograph images, and the other using CT scan images. Results Among a total of 126 pertrochanteric fractures, the A1 (stable) group consisted of 39 patients (10 males, 29 females), whereas the A2 (unstable) group consisted of 87 patients (14 males, 73 females) (not significant, NS). Intraclass correlation coefficient (ICC) values of PPM for the inter-observer agreement were 0.796 (0.723-0.852), 0.664 (0.554-0.751), and 0.702 (0.601-0.781) at first examination and 0.729 (0.635-0.801) at the second. The intra-observer agreement was 0.869 (0.819-0.906) and 0.603 (0.480-0.703). We examined for consistency of fracture classification group of PPM values with a threshold of 0.4 (A1<0.4, A2=0.4 or more) and CT-based group. For the first examination, there was mostly "moderate" agreement in fracture classification (stable or unstable) between plain radiograph and CT scan images, κ (95%CI): 0.427 (0.266-0.588), 0.493 (0.335-0.651), and 0.359 (0.176-0.544), and for the second,0.418 (0.251-0.585), and 0.451 (0.284-0.620), respectively. Conclusion We propose a supplementary tool, namely PPM that allows for possible alternative classification of pertrochanteric fractures into A1 (stable) and A2 (unstable) using plain radiograph images under the revised AO/OTA classification system. In this study, a PPM threshold value of 0.4 demonstrated a moderate inter- and intra-observer agreement. It is noteworthy to mention that there was a satisfactory consistency of fracture classification using PPM derived from plain radiograph images when compared to classification using CT scan images. In addition, the PPM method provides a numerical score.

Retropharyngeal Abscess Presenting as Torticollis.

Retropharyngeal abscess (RPA) is a deep neck infection with life-threatening complications such as airway obliteration, necrotizing mediastinitis, and pulmonary empyema, which must be diagnosed early and treated promptly. We herein present a patient who was admitted to the emergency room with limited neck movement, torticollis, difficulty in swallowing, and a feeling that something is stuck in the throat and diagnosed with RPA. Plain lateral radiograph of the neck revealed air levels at the level of C3-C5. Computed tomography (CT) scan confirmed the diagnosis of RPA. After emergency surgery, clinical condition normalised in a short time, and at a 2-week postoperative follow-up, the retropharyngeal area was completely normal on endoscopic examination. It is important to recognise and treat RPA, which has a high mortality due to its complications. RPA should be kept in mind in the differential diagnosis of patients with neck pain and torticollis, particularly in adults. Key Words: Retropharyngeal abscess, Drainage, Trendelenburg position, Torticollis.

Study on the Optimal Surgical Scheme for Very Severe Osteoporotic Vertebral Compression Fractures.

Therapy of very severe osteoporotic compression fractures (VSOVCF) has been a growing challenge for spine surgeons. Opinions vary regarding the optimal surgical procedure for the treatment of VSOVCF and which internal fixation method is more effective is still under debate, and research on this topic is lacking. This retrospective study was conducted to compare the efficacy and safety of various pedicle screw fixation methods for treating VSOVCF. This single-center retrospective comparative study was conducted between January 2015 and September 2020. Two hundred and one patients were divided into six groups according to different surgical methods: 45 patients underwent long-segment fixation (Group 1); 39 underwent short-segment fixation (Group 2); 30 received long-segment fixation with cement-reinforced screws (Group 3); 32 received short-segment fixation with cement-reinforced screws (Group 4); 29 had long-segment fixation combined with kyphoplasty (PKP) (Group 5); and 26 cases had short-segment fixation combined with PKP (Group 6). The clinical records were reviewed and the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) score were used for clinical evaluation. The vertebral height (VH), fractured vertebral body height (FVBH), and Cobb's angle were objectively calculated and analyzed on lateral plain radiographs. Student's t-tests and one-way ANOVA among groups were conducted to analyze the continuous, and the chi-squared test was used to compare the dichotomous or categorical variables. The difference was considered statistically significant when the P-value was less than 0.05. The six groups had similar distributions in age, gender, course of the disease, follow-up period, and injured level. In the postoperative assessment of the VAS score, the surgical intervention most likely to rank first in terms of pain relief was the short-segment fixation with cement-reinforced screws (Group 4). For the functional evaluation, the surgical intervention that is most likely to rank first in terms of ODI score was a short-segment fixation with cement-reinforced screws (Group 4), followed by long-segment fixation (Group 1). The long-segment fixation with cement-reinforced screws was the first-ranked surgical intervention for the maintenance of Cobb's angle and vertebral height, whereas the short-segment fixation performed the worst. The highest overall complication rate was in Group 6 with an incidence of 42.3% (11/26), followed by Group 2 with an incidence of 38.5% (15/39). For the treatment of VSOVCF, the short-segment fixation with cement-reinforced screws is the most effective and optimal procedure, and should be used as the preferred surgical method if surgeons are proficient in using cemented screws; otherwise, directly and unquestionably use long-segment fixation to achieve satisfactory clinical results.

Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making?

Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.

Patella-Posterior Turning Point of the Distal Femur Distance Is a Potential Indicator for Diagnosing Patella Alta in Recurrent Patellar Dislocation Population

To introduce a simple patellar height measurement method (patella-posterior turning point of the distal femur [P-PTP] Distance) independent of patellar anatomy with standardized patient position, and tested the reliability, validity, and diagnostic accuracy compared with commonly used ratios in knee extension. We retrospectively reviewed 418 computed tomography (CT) images of the knee joint in a group of patients who were diagnosed recurrent patellar dislocation (RPD). With the three-dimensional (3D) CT reconstructed knee, patellar height was qualitatively assessed by the patellar engagement with the femoral trochlea in terminal knee extension to divide RPD population into case (patella alta) and control group. With digitally reconstructed lateral radiographs, patellar height was measured with P-PTP distance (perpendicular distances between the distal edge of patella articular surface and posterior turning point of distal femur), and four commonly used ratios: Caton-Deschamps index, Modified Insall-Salvati index, Blackburne-Peel index, and Insall-Salvati index. An unpaired t-test was conducted to determine significant differences between groups. Correlation coefficient, intra- and inter-observer reliability, receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were also calculated. 198 knee images (198 patients) were included for final evaluation. Patella alta was present in 72 knees (36.3%) with RPD. The effect size was relatively large between the case and control group for P-PTP distance (d=-1.619; 95% CI,-1.948 to-1.286). P-PTP distance correlated moderately to strongly with four commonly used ratios (P < .001). Intraobserver and interobserver reliability was good for P-PTP distance. The AUC of the ROC curve was categorized as excellent for P-PTP distance, better than other measurements (P < .001), and the cutoff value was 4.2 mm with the highest sensitivity (86.11%) and specificity (84.92%). The measurement method, P-PTP distance, showed good intra-observer and inter-observer reliability, well correlated with commonly used ratios, and presented best diagnostic accuracy among commonly used ratios for predicting RPD. P-PTP distance might be a potential indicator for identifying patella alta in RPD patients when supine and knee extended. The measurement reported in this study may help in advancing clinical evaluation of patella alta, providing an alternative and simple method to measure patellar height. Standing or weight-bearing plain lateral radiographs obtained from the routine practice should be further assessed in the next step to further validate the method.

Quantifying the Spinal Lordosis Ratio Unique to the Type of Spinal Sagittal Alignment in a Normal Population.

Data collection of radiological parameters in non-pathological adult spines. Establishing a baseline database for measurements of the spinal lordosis ratio between upper and lower arcs of the lumbar spine unique to each type of spine described by Roussouly's classification. Illustrating the importance of correct rationing of the upper and lower arcs. Standardised standing true lateral plain radiographs of the spine (including base of skull and proximal femurs) from 373 adult volunteers were obtained. Exclusion criteria : any history of disease involving the spine, pelvis, hips or lower limbs. Incidental detection of any spinal deformity on radiography also excluded further participation in this study. Sacro-pelvic parameters data collected : Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), location of Inflection Point, number of vertebras in the spinal lordosis and type of Roussouly's spine. Values of upper arc, lower arc and spinal lordosis ratio (SLR) was determined. Bivariate analysis revealed statistically significant (P < .0001) correlation between the types of sagittal spinal alignments based on Roussouly's classification and the SLR. Type 1: SLR .76 ± .17, Type 2: SLR .60 ± .18, Type 3 with anteverted pelvis: SLR .53 ± .11, Type 3: SLR .49 ± .12, Type4: SLR .41 ± .11. With this data we are able to quantify the ratio of lumbar lordosis unique to each type of Roussouly's spine. It functions as a guide when planning lumbar spine surgeries in order to restore the SLR correctly and thus prevent post-op complications such as proximal junction kyphosis.

Neonatal Meconium Plug Caused Severe Proximal Small Bowel Dilatation and Made A Misinterpretation of Pneumoperitoneum

&lt;p&gt;There is a high mortality rate for infants with visceral perforations. Clinical imaging of this condition includes free air in the abdomen with abdominal plain radiography or lateral decubitus radiographs. An important disease that is easily ignored in the perinatal period is meconium plug syndrome, which causes functional obstruction in the colon that leads to dilated bowel loops in abdominal plain radiography. We report a female newborn who had a suspected bowel obstruction during prenatal examination because of polyhydramnios. The initial plain abdominal film showed a large volume of air accumulation in the peritoneum. An emergent exploratory laparotomy was performed and it revealed that there was no free a3 ir nor ascites in the peritoneal cavity. The proximal small bowel was severely dilated and a meconium plug at the splenic flexure was found. The image of air in the patient&amp;rsquo;s small bowel and peritoneal cavity in the anterior&amp;ndash;posterior view and image of the left decubitus view of the abdomen were similar in this case to the degree that the clinicians could not differentiate them, leading to an unnecessary exploration laparotomy.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Comparison of Dynamic Versus Static Lag Screw Modes for Short Cephalomedullary Nails in the Treatment of Unstable Intertrochanteric Fractures: A Randomized Controlled Trial

Purpose: To compare the static locked and sliding proximal lag screw modes of short cephalomedullary nail in the treatment of unstable intertrochanteric fractures. Methods: Ninety-four patients (age&gt;60 years) with low energy unstable intertrochanteric fractures were randomized for treatment into two groups. They were treated with static and sliding proximal lag screw modes of short cephalomedullary nail. The pre-operative variables, operative time, fluoroscopy time, blood loss, tip apex distance, and reduction quality were recorded for each patient. Post-operative follow-ups were undertaken every other week until bone union or implant failure occurred. Plain anteroposterior and lateral radiographs (both hip) were obtained at all visits. Ipsilateral leg length discrepancy (LLD), radiographic union score for hip complications, and fixation failure were recorded. Results: The mean follow-up time was 16.7 months (range 12–24). The mean bone union times of static locked (n=35) and sliding proximal (n=34) screw mode groups were 12.4 weeks and more than 11.2 weeks, respectively; the difference was not significant (p=0.213). The ipsilateral LLD of the sliding proximal (mean 4 mm) and static locked (mean 2 mm) screw mode groups showed a statistically significant difference (p&lt;0.001). Post-operative complications (lag screw perforated to hip joint, lag screw cutout from the femoral head, and excessive inferolateral lag screw sliding) developed in 8.82% patients in sliding proximal group, whereas, no complications were reported in the static locked group. Conclusions: Treatment of unstable intertrochanteric fracture using static locked proximal lag screw mode of cephalomedullary nail showed some advantages over sliding proximal lag screw in terms of less complication and ipsilateral LLD; however, the bone union times were not different. Therefore, a static locked proximal screw mode is preferable over sliding proximal screw mode in treating unstable intertrochanteric fractures.

Odontoid Incidence: A Novel Cervical Parameter Influencing Cervical Alignment From Top to Bottom.

ObjectiveBy using angulation of the axis itself, this study aims to define and analyze odontoid incidence (OI) and odontoid tilt (OT) as novel cervical alignment parameters and investigate their correlations with cervical alignment. MethodsNovel and existing parameters were measured with whole-spine lateral plain radiographs and EOS images of 42 adults without cervical symptoms. The correlations of OI, OT, C2 slope (C2S), and T1 slope (T1S) were calculated. ResultsThe OI, OT, and C2S showed significant correlations with C2–7 angle (r = 0.43, r = -0.42, r = 0.62, respectively) and C0–2 angle (r = -0.33, r = 0.48, r = -0.61, respectively). OI, OT, T1S were independent predictors of the C2–7 angle in univariate regression analysis (adjusted-R2 = 0.17, R2 = 0.15, R2 = 0.28, respectively). OI, OT, and T1S were independent predictors in the multivariable regression analysis with estimated standardized coefficients of 0.36, -0.67, -0.69, respectively (adjusted- R2 = 0.80, p < 0.001). Regarding the C0–2 angle, OI and OT were independent predictors in the univariate regression analysis (adjusted-R2 = 0.08, R2 = 0.21, respectively). ConclusionOI, OT, and C2S had significant correlations with cervical alignment. As the pelvic incidence, the OI is the only anatomical and constant parameter that could be used as a reference point related to the cervical spine from the rostral end. The study results may serve as baseline data for further studies on the alignment and balance of the cervical spine.

The Impact of Surgical Approach on Sagittal Plane Alignment in Patients Undergoing One- or Two- Level Fusions for Degenerative Pathology: A Multicenter Radiographic Evaluation 6 Months Following Surgery

Interbody fusion procedures, including transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF), effectively treat lumbar degenerative pathology and provide spinopelvic balance. The objective of this study is to compare changes in spinopelvic parameters 6 months following 1-2 level TLIF, PLIF, ALIF, and LLIF. This retrospective study included 18 centers across the United States. Patients were included in the study if they underwent a 1- or 2-level primary lumbar fusion for degenerative pathology. Preoperative and 6-month postoperative lumbar anteroposterior and lateral lumbar plain radiograph measurements included: pelvic incidence, pelvic tilt, lumbar lordosis from L1-S1, and segmental lordosis of each segment between L1 and S1. A total of 474 patients met inclusion criteria, with 632 levels that underwent fusion. Of these, 181 patients underwent an ALIF/LLIF on 381 levels, and 188 underwent a TLIF/PLIF on 252 levels. ALIF/LLIF procedures resulted in significantly more segmental lordosis (P<0.001) and global lumbar lordotic alignment change (P< 0.01) compared with TLIF/PLIF procedures. Whether patients' alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients' alignment was restored versus not corrected was not significantly predicted by procedure. In this large-scale multicenter study of lumbar fusion patients presenting with degenerative lumbar pathology, anteriorly placed grafts (ALIF/LLIF) led to a greater likelihood of patients being preserved rather than worsened in their spinopelvic mismatch. Posteriorly placed TLIF or PLIF grafts tended to worsen lordosis both segmentally and globally, yet even the anterior grafts only modestly improved those 2 same measurements.

Automatic recognition of whole-spine sagittal alignment and curvature analysis through a deep learning technique

PurposeArtificial intelligence based on deep learning (DL) approaches enables the automatic recognition of anatomic landmarks and subsequent estimation of various spinopelvic parameters. The locations of inflection points (IPs) and apices (APs) in whole-spine lateral radiographs could be mathematically determined by a fully automatic spinal sagittal curvature analysis system.MethodsWe developed a DL model for automatic spinal curvature analysis of whole-spine lateral plain radiographs by using 1800 annotated images of various spinal disease etiologies. The DL model comprised a landmark localizer to detect 25 vertebral landmarks and a numerical algorithm for the generation of an individualized spinal sagittal curvature. The characteristics of the spinal curvature, including the IPs, APs, and curvature angle, could thus be analyzed using mathematical definitions. The localization error of each landmark was calculated from the predictions of 300 test images to evaluate the performance of the landmark localizer. The interrater reliability among a senior orthopedic surgeon, a radiologist, and the DL model was assessed using the intraclass correlation coefficient (ICC).ResultsThe accuracy of the landmark localizer was within an acceptable range (median error: 1.7–4.1 mm), and the interrater reliabilities between the proposed DL model and each expert were good to excellent (all ICCs > 0.85) for the measurement of spinal curvature characteristics.ConclusionThe interrater reliability between the proposed DL model and human experts was good to excellent in predicting the locations of IPs, APs, and curvature angles. Future applications should be explored to validate this system and improve its clinical efficiency.

Direct Fixation of Fractures of the Posterior Malleolus Through a Postero-Medial Approach

Abstract Background and objective: Fractures of the posterior malleolus have long been neglected in the past. The decision for their fixation should be based on plain lateral radiographs. Recent studies have emphasized the important biomechanical function of the posterior tibial ridge. This has caused a trend towards more aggressive surgical treatment. The aim of this study was to present our experience with the direct fixation of complex ankle fractures engaging the posterior malleolus. We also tried to clarify the advantages and limitations of the posterior-medial surgical approach. Materials and Methods: For a period of 1,5 years we have operated 14 patients with posterior malleolus fractures. Their average age was 51 years. Eight of the patients were male, the rest 6 were females. Fractures were classified according to Bartoníček classification system. All patients had type 3 fractures. Direct open reduction was performed in all cases. Posterior buttress plate was used for the fixation of the fracture. Bone grafting was found necessary in one case. Functional assessment was done according to the criteria of the AOFAS (American Orthopedic Foot and ankle score). Follow up was done for an average period of 10 months. Results: All fractures united for an average period of 9 weeks (8-10 weeks). Six patients achieved an excellent functional result, 5 – a good one and 3 had an average result. The average AOFAS rating score was 84,02 (54-100). The average range of motion was 38° (15°-50°). There were no deep infections or septic arthritis. Three ankles had superficial skin necrosis that healed without any additional procedures. One patient had prolonged and substantial swelling of the leg, despite of the routine antithrombotic prophylaxis. Five patients needed their fibular plates removed due to local irritation. Conclusion: The direct reduction and fixation of the posterior malleolus fractures allow anatomical restoration of the ankle mortise. This is a prerequisite for an optimal functional recovery and appears to be a safe treatment strategy.

Functional Outcome of an Anatomically Contoured Locking Plate in Intra-Articular Pilon Fracture with MIPO Technique

Aim: To evaluate the outcome of osteosynthesis by using anatomically contoured locking plates in the management of intraarticular fractures of tibial plafond with minimally invasive plate osteosynthesis (MIPO) technique Methods: All the 50 patients presenting with intra-articular fractures (Pilon fracture type B and C) in the Accident and Emergency (A&amp;E) department were included in this study. The patients involved in high-energy trauma were treated according to advanced trauma life support guidelines for any associated life- or limb-threatening injuries. The clinical, functional, and radiographic plain anteroposterior and lateral radiographs) evaluations were conducted at 6 months according to Modified Klemm and Borner scoring system and outcome variables i.e. excellent to good was labeled. Results: There were 76% males and 24% females. Most of the patients 23(46%) were in &gt;45 years, age group. Among 50 patients, 28(56%) had type-B fractures, while 22(44%) had type-C fractures. 36(72%) had BMI &lt;30, while 14(28%) had BMI ≥30. 3(6%) had wound infections. Among 50 patients, 41(82%) had an excellent-good outcome. A good outcome was seen in male patients (78%), as compared to female patients. A good outcome was observed in 39% of patients with age greater than 45 years followed by 32% in 18-30 years. An almost equal percentage of good (56-44%) and poor (55.6-44.4%) outcomes were reported in both types of fractures. 70.7% of patients with BMI &lt;30 reported a good outcome. A good outcome was observed in 41 patients who do not have wound infection. However, 6 patients reported a poor outcome who didn’t have wound infection. Conclusion: Plate osteosynthesis using anatomically shaped locking plates via minimally invasive method is an efficient way of stabilization for distal tibia fracture when considering union rates and final functional outcome. Keywords: Intra-Articular Fracture, Pilon Fracture, Plate Osteosynthesis.

The impact of interbody approach and lumbar level on segmental, adjacent, and sagittal alignment in degenerative lumbar pathology: a radiographic analysis six months following surgery

Interbody fusion, including: transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF); effectively treat lumbar degenerative pathology and provide spinopelvic balance. Although the decision on surgical approach and technique are multifactorial and patient specific, the impact of the interbody approach on segmental and adjacent level lordosis could be an important factor to consider during pre-operative planning to achieve pre-specified alignment goals. The purpose of this study is to compare the 6-month postoperative radiographic outcomes in the lumbar spine following 1 to 2 level transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF) interbody fusions at the L3-4, L4-5, and L5-S1 levels. As our primary outcome, we evaluated the change in segmental lordosis at the level of fusion in ALIF/LLIF approaches compared to TLIF/PLIF. Secondarily, we evaluated the pelvic incidence to lumbar lordosis (PI-LL) mismatch and examined the compensatory lordotic changes at the adjacent levels 6 months following surgery. Retrospective cohort. This retrospective study included 18 centers of various practice settings across the United States. Patients were included in the study if they underwent a one- or two-level primary lumbar fusion for degenerative pathology. Measurements of the pre-operative and 6-month post-operative lumbar AP and lateral lumbar plain radiographs included: pelvic incidence (PI), pelvic tilt, lumbar lordosis from L1-S1 (LL), as well as segmental lordosis (SL) of each segment between L1-S1. Due to there being 2 evaluated time points, patients were then grouped based on alignment into categories of preserved, restored, not corrected, and worsened. 474 patients underwent 608 levels of fusion. ALIF/LLIF resulted in significantly more segmental lordosis compared to TLIF/PLIF procedures at both L4-5 and L5-S1 (p<.001). Overall, ALIF/LLIF resulted in significantly more global lumbar lordotic alignment change compared to TLIF/PLIF (p=.01). Whether patients' alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients' alignment was restored versus not corrected was not significantly predicted by type of procedure. Finally, anterior approaches resulted in decreased lordosis at adjacent levels, thus resulting in a more neutral position. In this large multicenter retrospective study of 1 to 2 level interbody fusion surgeries, we identified that A/LLIF procedures at L4-L5 and L5-S1 resulted in greater segmental lordosis restoration and PI-LL mismatch improvement compared to T/PLIF procedures. A/LLIF may also significantly reduce lordosis (compared to T/PLIF) at the adjacent levels in a fashion that serves to reduce the lumbar lordosis that may have been increased at the fused level.

Transconjunctival Approach: A Safe and Effective Access to Mass Lesions in the Anterior Orbit

The orbit is an eloquent organ of the body. Safe surgical access to the orbit could be challenging due to the dense network of critical structures confined to it. There are versatile approaches to different parts of the orbit that could be used by neurosurgeons without causing injury to critical neurovascular structures. In this study, we aimed to present our surgical experience with the transconjunctival approach through the bulbar conjunctiva to anterior intraorbital lesions caused by diverse pathologies. We conducted a retrospective review of cases with intraorbital lesions operated via the transconjunctival approach by the same senior surgeon between 2015 and 2017. All patients were evaluated before the surgery by computed tomography, magnetic resonance imaging, and plain anteroposterior and lateral radiographs. Five patients underwent surgery by the transconjunctival approach through the medial or lateral routes for different pathologies: cavernoma, lymphoma, inflammatory reaction, meningocele, and foreign body. No complications were recorded, and all patients were satisfied with their clinical and esthetic results. The transconjunctival approach is a safe, effective, and time-sparing surgical approach to diverse pathologies in the anterior orbit. Navigation systems enhance the ability to maneuver in selected cases. The transconjunctival approach could be performed in collaboration with ophthalmologists since it provides better esthetic outcomes and higher satisfaction rates in operated patients.

Comparison of 3D Surface Rendering CT to Plain Lateral Radiographs for Quantification and Characterisation of Posterior Malleolar Fracture Fragment Size and Morphology

Category:Ankle; TraumaIntroduction/Purpose:The aim of this study was to compare the size of the posterior malleolar fracture (PMF) fragment on plain lateral radiographs compared to three-dimensional (3D) surface rendering CT imaging, and to compare both modalities in the characterisation of PMF morphology.Methods:Measurements of 180 lateral radiographs of PMF's were compared to their respective 3D surface rendering CT reconstructions, by two independent observers reviewing percentage articular involvement of the PMF fragment. Morphology of the PMF was categorised initially by the CT scan as classified by Mason and Molloy and was compared to this classification using radiographs.Results:When calculating the percentage joint surface involved by the PMF fragment, inter-observer variability was greater than 0.8 for radiographic and CT measurement. Significant differences in size of PMF on radiograph compared to CT were found for type 1 and type 2A fractures (p<0001 type 1, p=.071 type 2A). Radiographs consistently over-estimated the PMF fragment size, although in type 2B fracture patterns there was an equivalent number that were under-estimated due to the underappreciation of the posteromedial fragment. Comparison of fracture fragment morphology found that type 2A and 2B fractures (rotational Pilon's) had poor agreement between radiographs and CT (34.15%).Conclusion:This study shows that the use of a lateral radiograph in a PMF to estimate fracture size and morphology is poor. Additional CT imaging is imperative to allow for appropriate treatment planning in the management of PMF.