Postoperative Computed Tomography Scans Research Articles

Evaluation of Preoperative Factors That Affect the Alpha Angle of Screw Insertion After the Open Latarjet Procedure.

The open Latarjet procedure yields excellent results as a treatment for anterior shoulder instability. The position of the bony fragment and the insertion angle of the screw (the alpha angle) are critical factors for a successful procedure. The alpha angle is considered overangulated at >25°, which is associated with poor bone fixation and healing. To assess preoperative patient anatomic factors that affect the alpha angle in the Latarjet procedure for anterior shoulder instability. Case-control study; Level of evidence, 3. In this retrospective study, 76 patients who underwent the open Latarjet procedure between October 2009 and December 2023 were included. Postoperative computed tomography scans were reviewed for the alpha angle, and patients were classified into 2 groups: group 1 (alpha angle ≥25°) and group 2 (alpha angle <25°). Preoperative patient characteristics and radiological parameters obtained from preoperative computed tomography scans were analyzed and compared between groups 1 and 2. We developed a novel method to measure the depth of the chest and the angle between the deltopectoral interval and the plane of screw insertion. We also measured the thickness of the pectoralis major and subscapularis muscles. Of the 76 patients in this study, 41 and 35 patients were included in groups 1 and 2, respectively. The mean alpha angles of groups 1 and 2 were 36° and 12°, respectively, and the body mass index was significantly higher in group 1 (P < .001). In addition, group 1 had a significantly longer distance from the anterior edge of the glenoid to the skin margin of the deltopectoral interval (P < .001). The angle between the deltopectoral interval and the plane of screw insertion (traction angle) was significantly larger in group 1 (P < .001), and the pectoralis major and subscapularis muscles were thicker in group 1 (P = .017 and P = .032, respectively). The alpha angle after the Latarjet procedure was strongly related to the patient's weight, body mass index, depth of the chest, and the angle between the deltopectoral interval and the plane of screw insertion. To our knowledge, this is the first study in which the preoperative factors that facilitate proper screw fixation in the Latarjet procedure are reported.

Penetrating intraorbital wooden foreign bodies involving the right frontal lobe of the brain: A rare case report

Background: Penetrating orbital trauma from a wooden foreign object is rare and challenging to identify, as it cannot be detected with a computed tomography (CT) scan. This report highlights the clinical presentation, diagnosis, and management of such a case. Case Description: A 19-year-old female experienced penetrating orbital trauma from a wooden object following a traffic accident. She intermittently visited the hospital with eye swelling and headache, without visible penetrating wounds on the palpebra. The swelling persisted for weeks, accompanied by increasing signs of ocular and cerebral infection. The suspicion of a non-metallic foreign body penetrating the brain was confirmed 3 months after the initial visit, delayed by the hidden entry wound between the eyelid and eyeball and orbital edema mimicking non-penetrating trauma. A multidisciplinary team managed the case. Procedures included debridement, retro-orbital exploration, retro-orbital abscess evacuation, and frontal basal trephination exploration, successfully removing the wooden object that had penetrated the medial orbit, frontal bone, and brain, along with cerebral abscess evacuation. Postoperative CT scans showed complete removal of the foreign object and successful abscess evacuation. The patient showed improvement in ocular symptoms, resolution of headaches, and no wound leakage. She was discharged on the 14th day after completing antibiotic treatment and having the dressing removed. Conclusion: This case is notable for its rarity, high risk of misdiagnosis, and potentially fatal consequences if not promptly managed. We emphasize the importance of patient involvement in routine consultations, careful anamnesis, clinical examination, and a multidisciplinary approach for optimal outcomes.

X-ray guided anatomy-based fitting: The validity of OTOPLAN.

Anatomy-based fitting (ABF) for cochlear implant users is a new era that seeks improved outcomes. Recently, different imaging modalities, such as plain X-rays, have been proposed to build the ABF as an alternative to the computed tomography (CT) scan. This study aimed to assess the feasibility and validity of OTOPLAN® software in building ABF using plain X-ray imaging. A retrospective evaluation of postoperative CT scans and plain X-ray post-op images of 54 patients was analyzed using the OTOPLAN® software. The post-op analysis was done for the angular insertion depth (AID) and center frequency of each electrode contact using both imaging modalities. Moreover, inter-rater reliability was assessed for measurements obtained from CT scans and plain X-ray images. Non-significant statistical and clinical mismatches were detected when comparing the AID and center frequency measurements assessed using CT and X-rays. The absolute difference between CT and X-ray approaches ranged from 0.0 to 4.6 degrees for AID and 0.2 to 0.5 semitone for frequency. Moreover, the AID and the frequency measurements from CT and X-ray images demonstrated almost perfect agreement between the raters. The inter-observer reliability for CT scans showed that the intraclass correlation coefficient (ICC) exceeded 0.97 for AID and 0.95 for the frequency across all electrode contacts. Our results demonstrated the validity and reliability of using post-operative X-ray images by OTOPLAN® software to build Anatomy-based Fitting maps.

Robotic Pedicle Screw Placement with 3D MRI Registration: Moving Towards Radiation Free Robotic Spine Surgery

BACKGROUND CONTEXTPreoperative imaging for lumbar spine surgery often includes magnetic resonance imaging (MRI) for soft tissues and computer tomography (CT) for bony detail. While CT scans expose patients to ionizing radiation, whereas MRI scans do not. Emerging MRI techniques allow CT-like three-dimensional (3D) visualization of bony structures, potentially removing the need for ionizing radiation from CT scans. PURPOSEThis study aims to explore the accuracy of robot-assisted lumbar pedicle screw placement based on preoperative CT-like 3D MRI as the data source for robotic registration. STUDY DESIGNHuman cadaveric study. METHODS: CT-like 3D MRI scans of the lumbar spine were acquired in ten human cadavers. A robotic navigation platform was used to plan and navigate pedicle screw placement based on the CT-like 3D MRI. Postoperative CT scans assessed the accuracy of screw positioning compared to preoperative planning based on the Gertzbein-Robbins scale (GRS) and by direct measurement (mm). RESULTSA total of 100 lumbar pedicle screws were robotically placed in ten cadavers (L1 through L5 bilaterally) based on CT-like 3D MRI. On postoperative CT evaluation, 99.0% of the positioned screws achieved an acceptable grade on the GRS (Grade A: n = 89 or Grade B: n = 10), with 89.0% classified as Grade A and 10.0% as Grade B. Meaning that 89.0% of screws were fully contained within the pedicle (GRS A), and 10% had a minor cortical breach <2mm (GRS B). The median deviation from the planned trajectory was 0.2 mm (axial IQR: 0.1 to 0.5 mm; sagittal: IQR: 0.1 to 0.4 mm), in both axial and sagittal planes. CONCLUSIONThis study showed that image registration of CT-like 3D MRI for robotic-assisted spine surgery is technically feasible and that accurate pedicle screw placement can be achieved without preoperative CT. Each CT-like 3D MRI was successfully registered for robotic navigation. CLINICAL SIGNIFICANCEThe results suggest that CT-like 3D MRI has the potential to be a radiation-free alternative for preoperative planning and navigation in lumbar spine instrumentation procedures.

Lipoprotein(a) and High-Sensitivity C-Reactive Protein Compound the Risk of Hypoattenuating Leaflet Thickening After Transcatheter Aortic Valve Replacement.

The mechanism for hypoattenuating leaflet thickening (HALT) after transcatheter aortic valve replacement is still not well elucidated, and the role of Lp(a) (lipoprotein[a]) and hs-CRP (high-sensitivity C-reactive protein) has rarely been studied. This study sought to test the hypothesis that the risk of HALT is associated with an elevated level of Lp(a) or hs-CRP. A total of 307 consecutive individuals who underwent a transcatheter aortic valve replacement procedure were included. All patients received their first postoperative computed tomography scans within 12 months, and raw data were analyzed on 3mensio software. HALT was defined as visually identified increased leaflet thickness with typical meniscal appearance and at least 2 different multiplanar reformation projections. Associations of Lp(a) or hs-CRP with the risk of HALT were evaluated using multivariable logistic regression analysis. The incidence of HALT within 12 months after transcatheter aortic valve replacement in this study was 36.2%, and the risk of HALT was associated with higher baseline Lp(a) (the multivariable adjusted odds ratio [OR] for every 10 mg/dL change was 1.18 [95% CI, 1.09-1.29]) and hs-CRP level (the multivariable adjusted OR for every 1 mg/L change was 1.08 [95% CI, 1.00-1.27]). Compared with individuals out of the top 25th percentile for both Lp(a) and hs-CRP, the multivariable adjusted OR for HALT was 4.74 (95% CI, 1.65-14.37) for the top 25th percentile. This result remained consistent after excluding patients receiving anticoagulant therapy. The top 25th percentile of Lp(a) level (≥40 mg/dL) combined with the top 25th percentile of hs-CRP level (≥3.5 mg/L) conferred a 4.74-fold risk of HALT.

Does More Invasive Surgery Result in Higher Patient Satisfaction? A Long-Term Follow-Up of 136 Zygomaticomaxillary Complex Fractures.

Retrospective with follow-up. To evaluate the long-term satisfaction of surgically treated patients with zygomaticomaxillary complex (ZMC) fractures in relation to the use of internal fixation, number of fixation points, and orbital floor (OF) reconstruction. Secondary objectives were to describe the use of antibiotics and post-operative infections. Patients with unilateral ZMC fractures between 2007-2018 and treatment with either open reduction and internal fixation (ORIF) or closed reduction (CR) were identified from medical records and invited to follow-ups between 2018-2020. Patients were examined, photographed, and completed a questionnaire. A review panel of 3 experienced surgeons evaluated photographs and computed tomography (CT) scans pre- and post-surgery. The study sample consisted of 136 patients (108 ORIF, 28 CR) with a median follow-up time of 76 months. Patient satisfaction of surgical outcome was high (97.8%), with no significant differences in relation to the use of internal fixation, number of fixation points, or OF reconstruction. Dissatisfaction was primarily related to hypoesthesia. On post-operative CT scans, malar asymmetry was more often predicted in patients with 1-point fixations. On questionnaires and photographs, malar asymmetry was more common in patients with 3-point fixations. Prophylactic antibiotics had no effect on the rate of post-operative infections. Patient satisfaction was not influenced by internal fixation, number of fixation points, or OF reconstruction. Selected ZMC fractures can be treated with less invasive approaches. Caution should be observed when predicting long-term malar asymmetry on post-operative CT scans. The findings of this study highlight the importance of a rational and ethical use of surgery.

Intranasal Outer Cortex Splinting With a Kirschner Wire to Immobilize Reduced Buckle-out Segments in Nasal Fractures

High-velocity lateral impacts to the nose sometimes cause nasal buckle-out fractures with a trapdoor buckle-out segment displaced outwards. Prolonged immobilization of a reduced buckle-out segment at risk for outward redisplacement remains challenging. Here we introduce a novel method of intranasal outer cortex splinting with a Kirshner (K)-wire to reinforce the reduced state and prevent outward re-displacement of the buckle-out segment. Eighteen patients with nasal buckle-out fractures underwent outer cortex K-wire splinting to securely immobilize a reduced but unstable buckle-out segment after indirect open reduction through intercartilaginous incisions and inner cortex K-wire splinting. A thin K-wire (diameter 0.8 mm) was inserted at the vestibule, passed above the upper lateral cartilage and the outer cortex of the reduced buckle-out segment, and extended to the cephalic non-fractured bone. The wire served as a crossbeam, effectively supporting the reduced buckle-out segment. All K-wires for inner and outer cortex splinting were removed 10 to 14 days postoperatively. Immediate postoperative computed tomography scans showed successful immobilization of buckle-out segments in 17 patients (94.5%). Postoperative 6-month scans of 7 patients showed excellent maintenance and bony alignment of buckle-out segments in all cases. Sixteen patients (88.9%) were satisfied with the overall external nasal contour at the last follow-up. There were no complications directly related to outer cortex K-wire splinting. One patient complained of a focal lateral protrusion resulting from the under-correction of a buckle-out segment. This technique may be a valuable option for immobilizing and maintaining reduced nasal buckle-out segments until a stable bony union is established.

Delayed Maxillary Reconstruction with Free Osteocutaneous Fibula Flap Using CAD-CAM Technology

Abstract Background Maxillary reconstruction poses unique challenges for the reconstructive surgeon because of the complex three-dimensional (3D) anatomy of the maxilla. Undertaking this endeavor on secondary reconstruction makes it more difficult due to problems in recreating the true defect. This study is an attempt to demonstrate the role of virtual surgical planning (VSP), 3D printing, and mock surgery in reconstructing such defects using free fibula flaps. Materials and Methods This was a prospective study involving 10 patients of maxillary defects who underwent delayed reconstruction with a free fibula flap. The planning was done preoperatively using computer-aided design and computer-aided manufacturing (CAD-CAM) technology. A mock surgery with 3D printed models was done before the surgery. After the surgery, the accuracy results were obtained by overlapping and measuring fixed point distances between preoperative virtual planning and postoperative computed tomography (CT) scan data. Results and Discussion Nine patients underwent successful reconstruction and were satisfied with the outcome. One patient had flap loss. The mean shift along the horizontal, vertical, and 3D axes was less than 5 mm between the preoperative virtual planning and postoperative CT scan data, indicating accurate reconstruction. We also suggest strategies for soft-tissue and bony inset including inferolateral pedicle origin, anteriorly facing lateral fibular surface, and two bony struts for the alveolus. Conclusion VSP and CAD-CAM technology in maxillary reconstructions help achieve an anatomically accurate neo-maxilla. The addition of mock surgery to the routine and the use of cutting guide avoid unpredictability and reduce the need for adaptation activities on the operating table. CAD-CAM technology despite its limitations is invaluable in maxillary reconstruction and is an important tool for a reconstructive plastic surgeon.

Accelerometer-based portable navigation system shows no superior accuracy over pelvic alignment guide for acetabular cup placement in total hip arthroplasty in lateral decubitus position.

Total hip arthroplasty (THA) using a portable navigation system (PNS) incurs costs per procedure. However, it does not require a large console. This study aimed to compare the accuracy of acetabular cup placement using a pelvic alignment guide (PAG) attached to the pelvis and an accelerometer-based PNS in THA performed in the lateral decubitus position. We retrospectively analyzed 100 hips that underwent primary THA in the lateral decubitus position between July 2018 and January 2021. The PAG was used in 50 hips, whereas the PNS was used in the other 50. Cup placement accuracy was measured using postoperative computed tomography scans, comparing errors in inclination and anteversion angles. The surgical time, blood loss, and complications were recorded. The follow-up period was at least 2 years in all cases. The mean absolute error of the inclination angle was similar between the groups (the PAG group: 3.7° ± 2.3° [range, 0.0-9.0]; the PNS group: 3.7° ± 2.3° [range, 0.2-10.5], p = 0.705). The mean absolute error of the anteversion angle was significantly smaller in the PAG group than in the PNS group (3.0° ± 2.4° [range, 0.0-9.7] vs. 6.5° ± 4.8° [range, 0.3-17.3], p < 0.001). The PAG group had a higher proportion of hips within 5° and 10° of the target angle (64 vs. 42%, P = 0.028, and 100 vs. 74%, p < 0.001, respectively). The PNS group had six hips with anteversion errors of 15° or more. Surgical time and blood loss were lower in the PAG group. The PNS group had one dislocation, whereas the PAG group did not. The accelerometer-based PNS did not demonstrate superior cup alignment accuracy compared to the PAG in THA performed in the lateral decubitus position. This finding informs surgeons that computer-assisted surgery is not necessarily superior to conventional THA using a PAG.

Risk factors for proximal and distal aortic events after type A acute aortic dissection.

Type A acute aortic dissection (TAAAD) is a life-threatening condition often requiring emergency surgery, with approximately 30% of patients needing reoperation. This study aimed to identify predictors of long-term aortic events from early postoperative computed tomography (CT) examinations. A total of 336 cases underwent TAAAD surgery at two institutions between 2002 and 2018. Of these, 302 patients received CT examinations immediately after initial TAAAD surgery. Predictors of aortic events were evaluated from these early postoperative CT exams. Aortic events were defined as any events involving aortic-related death, open surgery, reoperation, endovascular stenting, or thoracic aorta diameter enlargement to ≥ 55mm. Excluding 34 in-hospital deaths (10.1%; 34/336), the 1-, 5-, and 10-year actuarial survival rates after primary TAAAD surgery were 98.2%, 88.6%, and 81.7%, respectively. Over a mean follow-up period of 7.4 ± 5.1years, 67 aortic events (proximal: 19, distal: 45, both: 3) were observed. Freedom from proximal aortic events was 98.6%, 93.9%, and 85.2% at 1, 5, and 10years, respectively. Proximal anastomosis new entry was identified as a significant risk factor for aortic events, with a 92% vs. 42% incidence at 10years (p < 0.001). Freedom from distal aortic events was 99.6%, 84.5%, and 67.2% at 1, 5, and 10years, respectively. A false/true area ratio greater than 1 and distal anastomosis new entry were significant risk factors for aortic events (low-risk group: 83.3% vs. high-risk group: 42.3% at 10years, p < 0.001). Detailed analysis of early postoperative CT scans following primary TAAAD surgery may help identify predictors of subsequent aortic events, potentially improving long-term patient management and outcomes.

Assessing adequacy of surgical extent in CRSwNP: The Completion of Surgery Index.

Endoscopic sinus surgery (ESS) maximized for topical steroid irrigations is highly effective for polyp disease. As extent and completeness of ESS varies widely by situation and practitioner, it is important to understand when revision surgery is appropriate, particularly in the era of biologic treatments. A Completion of Surgery Index (CoSI) was developed to assess operative changes in polyp patients using pre- and postoperative computed tomography scans. The CoSI was then applied and tested in a cohort of consecutive chronic rhinosinusitis with nasal polyps (CRSwNP) patients, and examined within the context of quality-of-life improvements. The CoSI assesses surgical extent on a scale of 0-100, with 100 representing the highest possible degree of surgical completeness. Among 100 consecutive CRSwNP patients undergoing ESS in 2021 with postoperative topical steroid irrigations, including 75 revision surgeries, SNOT-22 scores improved at 6months postoperatively, with durable and consistent improvement at 24months (p<0.001). Preoperative CoSI scores in revision surgery patients were 49.4±26.0, improving to 91.0±8.1 postoperatively. SNOT-22 scores for primary ESS patients and patients with a preoperative CoSI score of less than 70 improved by 26.4 and 28.1 points, respectively, in contrast to patients with a preoperative CoSI of 70 or greater (14.1 points, p=0.029). It is important to define extent of surgery in CRSwNP to stratify postsurgical patients based on likelihood to benefit from revision surgery or alternative medications. The CoSI can be utilized to identify patients who are likely to improve significantly with revision surgical intervention.

Functional preoperative assessment of coronal knee laxity better predicts postoperative patient outcomes than intraoperative surgeon-defined laxity in total knee arthroplasty.

Intraoperative laxity assessments in total knee arthroplasty (TKA) are subjective, with few studies comparing against standardised preoperative and postoperative assessments. This study compares coronal knee laxity in TKA patients awake and anaesthetised, preprosthesis and postprosthesis implantation, evaluating relationships to patient-reported outcome measures. A retrospective analysis of 49 TKA joints included preoperative and postoperative computed tomography scans, stress radiographsand knee injury and osteoarthritis outcome score (KOOS) questionnaire results preoperatively and 12 months postoperatively. The imaging was used to assess functional laxity (FL) in awake patients, whereas computer navigation measured intraoperative surgical laxity (SL) preimplantation and postimplantation, with patients anaesthetised. Varus and valgus stress states and their difference, joint laxity, were measured. SL was greater than FL in both preimplantation [8.1° (interquartile range, IQR2.0°) and 3.8° (IQR 2.9°), respectively] and postimplantation [3.5° (IQR 2.3°) and 2.5° (IQR 2.7°), respectively]. Preimplantation, SL was more likely than FL to categorise knees as correctable to ±3° of the mechanical axis. Preoperative FL correlated with KOOS Symptoms (r = 0.33, p = .02) and quality of life (QOL) (r = 0.38, p = .01), whereas reducing medial laxity with TKA enhanced postoperative QOL outcomes (p = .02). Functional coronal knee laxity assessment of awake patients is generally lower than intraoperative surgical assessments of anaesthetised patients. Preoperative SL may result in overcorrection of coronal TKA alignment, whereas preoperative FL better predicts postoperative patient outcomes and reflects the patients' native and tolerable knee laxity. Preoperative FL assessment can be used to guide surgical planning. Level II.

Clinical and radiological outcome of extended lateral approach via epicondyle osteotomy in complex lateral tibia plateau fractures involving the central and postero-lateral segments

IntroductionThe purpose of this study was to evaluate the clinical and radiological results of complex lateral tibial plateau fractures involving the central segments of the lateral tibial plateau. It was hypothesized that an extended lateral approach by using the lateral epicondyle osteotomy improves the rate of malreduction and yields to good and excellent clinical results at a mid-term follow-up. MethodsThis retrospective case series conducted at two centers evaluated complex lateral tibial plateau fractures treated with an extended lateral approach by lateral epicondyle osteotomy. Fractures were classified according to the AO/OTA and 10-segment classification, with only B/C type fractures involving the antero-latero-central (ALC) and postero-latero-central (PLC)/postero-latero-lateral (PLL) segments. Postoperative computer tomography scans were used to assess the quality of reduction. Clinical outcomes and postoperative complications were evaluated with a minimum follow-up of 2 years. ResultsSixty-five patients (mean age: 47.7 ± 11.5 years) were included, with an average follow-up of 51.9 ± 3.6 months. Radiological outcomes revealed a postoperative fracture step at the ALC/PLC crossing of 0.8 ± 1.1 mm, at the PLC/PLL crossing of 0.4 ± 1.1 mm, and a fracture gap of 1.8 ± 4.0 mm, yielding a Rasmussen Score of 15.1 ± 3.2. No significant differences among type B and C fractures were identified. No case of nonunion of the lateral epicondyle osteotomy was recorded. The mean Knee injury and Osteoarthritis Outcome Score was 80.4 ± 16.2 (type B 85.6 ± 11.9 vs. type C 76.1 ± 18.4, p < 0.05), Lysholm score was 83.4 ± 17.1 (B 89 ± 11.3 vs. C 78.7 ± 20.1, p < 0.05) and International Knee Documentation Committee score was 69.9 ± 18.8 (type B 76.5 ± 15.7 vs. type C 64.3 ± 20.1, p < 0.05). Early complication rate requiring surgical revision due to malreduction or infection were 7 %. None of the patients reported about subjective lateral knee instability at the time of clinical follow-up. ConclusionThe extended lateral approach with lateral epicondyle osteotomy demonstrated excellent radiological alignment and favorable mid-term clinical outcomes. An overall low complication rate was recorded. Notably, long-term revisions due to lateral instability were absent, indicating the safety and efficacy of lateral epicondyle osteotomy as an operative technique.

Clinical validation of artificial intelligence-based preoperative virtual reduction for Neer 3- or 4-part proximal humerus fractures

BackgroundIf reduction images of fractures can be provided in advance with artificial-intelligence (AI)-based technology, it can assist with preoperative surgical planning. Recently, we developed the AI-based preoperative virtual reduction model for orthopedic trauma, which can provide an automatic segmentation and reduction of fractured fragments. The purpose of this study was to validate a quality of reduction model of Neer 3- or 4-part proximal humerus fractures established by AI-based technology.MethodsTo develop the AI-based preoperative virtual reduction model, deep learning performed the segmentation of fracture fragments, and a Monte Carlo simulation completed the virtual reduction to determine the best model. A total of 20 pre/postoperative three-dimensional computed tomography (CT) scans of proximal humerus fracture were prepared. The preoperative CT scans were employed as the input of AI-based automated reduction (AI-R) to deduce the reduction models of fracture fragments, meanwhile, the manual reduction (MR) was conducted using the same CT images. Dice similarity coefficient (DSC) and intersection over union (IoU) between the reduction model from the AI-R/MR and postoperative CT scans were evaluated. Working times were compared between the two groups. Clinical validity agreement (CVA) and reduction quality score (RQS) were investigated for clinical validation outcomes by 20 orthopedic surgeons.ResultsThe mean DSC and IoU were better when using AI-R that when using MR (0.78 ± 0.13 vs. 0.69 ± 0.16, p < 0.001 and 0.65 ± 0.16 vs. 0.55 ± 0.18, p < 0.001, respectively). The working time of AI-R was, on average, 1.41% of that of MR. The mean CVA of all cases was 81%±14.7% (AI-R, 82.25%±14.27%; MR, 76.75%±14.17%, p = 0.06). The mean RQS was significantly higher when AI-R compared with MR was used (91.47 ± 1.12 vs. 89.30 ± 1.62, p = 0.045).ConclusionThe AI-based preoperative virtual reduction model showed good performance in the reduction model in proximal humerus fractures with faster working times. Beyond diagnosis, classification, and outcome prediction, the AI-based technology can change the paradigm of preoperative surgical planning in orthopedic surgery.Level of evidenceLevel IV.

Intraoperative computerised tomography scan for percutaneous fixation of the pelvis: a retrospective case series

PurposeFractures and dislocations of the pelvic ring are complex injuries that when treating require meticulous attention to detail and often specialized technical skill. These injuries can be the result of high-energy trauma, particularly in younger patients, or low energy trauma more often found in the elderly. Regardless of mechanism, these injuries lie on a spectrum of severity and can be treated conservatively or surgically. Percutaneous fixation under fluoroscopic guidance is the preferred standard technique when treating these fractures. This technique can be challenging for a variety of reasons including patient characteristics, intra-operative image quality, fracture morphology, among others.MethodsThis retrospective study evaluated the use of intra-operative computed tomography (CT) using an O-arm imaging system for critical evaluation of fluoroscopic-guided screw placement in twenty-three patients. We retrospectively reviewed all cases of patients who were treated by three fellowship-trained orthopaedic traumatologists during a one-year span. Patients undergoing percutaneous pelvis fixation using both standard fluoroscopy and intraoperative CT with the Medtronic O-arm® (Minneapolis, MN) imaging system. Additionally, procedures performed included open reduction internal fixation (ORIF) of the pelvic ring, acetabulum, and associated extremity fractures.ResultsTwenty-three patients were included in this study. On average, the use of intraoperative CT added 24.4 min in operative time. Five patients (21.7%) required implant adjustment after O-arm spin. Fourteen patients underwent additional post-operative CT. No secondary revision surgeries were attempted after any post-operative CT.ConclusionsOur study suggests that intra-operative CT scan, compared to post-operative CT scan, can be utilized to prevent take-back surgery for misplaced implants and allow for adjustment in real-time.

Early Bone and Suture Reformations in Different Cranial Regions After Cranial Vault Remodeling for Sagittal Craniosynostosis.

Cranial vault remodeling (CVR) is a common procedure for correcting sagittal craniosynostosis. Some approaches leave significant craniectomy defects. The authors investigated the reosteogenesis in different cranial defect areas after CVR. A cross-sectional study was conducted in nonsyndromic sagittal craniosynostosis. Available early postoperative computed tomography (CT) scans were analyzed. The segmentation of three-dimensional reconstructed images was performed. Different cranial defect areas, including coronal, vertex, and occipital regions, were further investigated using an automated three-dimensional analysis software for reosteogenesis percentage. Forty-four CT scans were included. The average age at CVR was 8.8 months. The median time of postoperative CT scans was 6.1 weeks. The median bone reformation percentage of the entire cranial defect was 56.7%. Given the similar postoperative CT timing, the median bone reformation at the coronal, vertex, and occipital areas demonstrated 44.21%, 41.13%, and 77.75%, respectively (P < 0.001). In the simultaneously removed coronal and lambdoid sutures, there were 45% with coronal and lambdoid sutures reformation, followed by lambdoid suture reformation alone, no suture reformation and coronal reformation alone in 35%, 20%, and 0%, respectively (P = 0.013). There was no coronal reformation in the removed coronal suture group. However, 40% demonstrated lambdoid suture reformation after the isolated lambdoid suture removal. The occipital region has the highest reosteogenesis compared with the other cranial defects after CVR in nonsyndromic sagittal craniosynostosis. Within the removed previous patent sutures, the lambdoid suture reformation showed a higher rate than the coronal suture.

Which type of supra-syndesmal fractures Weber C or Equivalent Weber C have the best reduction of the distal tibio-fibular syndesmosis? A prospective CT-scan investigation on 60 ankles

IntroductionThe reduction of the distal tibiofibular syndesmosis (SyTFd) is a crucial factor in the functional prognosis following a suprasyndesmotic ankle fracture. Few studies have compared, using computed tomography (CT), the quality of SyTFd reduction in Weber C ankle fractures (WebC) and Equivalent Weber C (EqWebC) fractures, where there is a medial ligament injury instead of a bony malleolar lesion. This CT-based study aimed to answer the following questions: (1) Do Weber C fractures allow for better reduction of the distal tibiofibular syndesmosis compared to Equivalent Weber C fractures? (2) Are the functional outcomes one year postoperatively better for Weber C fractures compared to Equivalent Weber C fractures? HypothesisThe hypothesis was that WebC fractures would present better reduction of the SyTFd than EqWebC fractures due to the restoration of bone anatomy, considering the bony nature of the medial ligament involvement. Materials and methodsSince December 2021, all patients presenting with an ankle fracture were included in a database. Suprasyndesmotic fractures were extracted, and between December 2021 and February 2022, 60 patients underwent surgery for a suprasyndesmotic fracture (28 WebC – 32 EqWebC). All patients were operated on using the same technique and underwent a postoperative bilateral CT scan in axial slices with both ankles in a neutral position (foot at 90 ° to the leg). An analysis of 8 measurements was performed under the same conditions. Each fractured ankle was compared to the healthy contralateral ankle, and a delta was obtained for each measurement. The follow-up was standardized. At one year, an AOFAS Score and a Maryland Foot Score (MFS) were recorded. Statistical differences between the two groups were measured using the Student's t-test and Chi-square test. ResultsThere was a significant difference between the WebC and EqWebC groups for clinical scores at one year postoperatively: AOFAS: 92.0 ± 6.3 [78–100] vs. 80.1 ± 5.4 [62–100], p < 0.05; MFS: 90.9 ± 6.4 [78–100] vs. 81.6 ± 5.2 [64–100], p < 0.05. CT scan analysis of the SyTFd reduction found significantly better reduction in the WebC group. DiscussionWebC fractures showed better clinical scores associated with better SyTFd reduction on postoperative CT scans. The anatomical reduction related to the bone reduction criteria during surgery could explain our findings. Level of evidenceIII; Case-Control Comparative Study.

Structural bone grafting with reverse shoulder arthroplasty for osteoarthritis with severe glenoid bone loss: outcomes using a long post

Severe posterior glenoid bone loss with glenohumeral osteoarthritis with an intact rotator cuff can be managed with reverse shoulder arthroplasty but requires lateralization and version correction to avoid potential complications, such as instability, notching and implant failure. Angled bone grafting with humeral head autograft can provide durable glenoid bone stock, but results have been mixed. The purpose of this study was to evaluate patient-reported and objective outcomes as well as complication and failure rates for patients who underwent angled humeral head autografting for severe retroversion. All patients who underwent a primary reverse shoulder arthroplasty with angled humeral head autograft and Stryker Tornier long central postbaseplate for severe glenoid bone loss in the setting of glenohumeral osteoarthritis with an intact rotator cuff at our institution between November 2018 and February of 2022 were identified. Individuals with a primary diagnosis of osteoarthritis and preoperative glenoid retroversion of ≥30° were included. Patients undergoing revision procedures, planned 2-stage arthroplasty were excluded. Differences in pre- and postoperative range of motion, as well as patient-reported outcomes were assessed. Intraoperative complications, postoperative complications, and re-operation rates were analyzed. A total of 24 shoulders in 23 patients (61% male), with a mean age of 65.6years were included. Average preoperative retroversion was 37.4° (range: 30°-51°). Mean follow-up was 2.9years (range: 2-4.3years). Significant improvements were found in flexion, abduction, and external rotation. Patient-reported subjective outcomes were excellent, with average American Shoulder and Elbow Surgeons score of 93.6 and average Subjective Shoulder Value score of 93.8%. Sixteen (67%) shoulders received postoperative computed tomography scans and all were found to have incorporated. Complications included one shoulder hematoma requiring incision and drainage without revision, and a post-traumatic fracture of the inferior glenoid screw at 11months, requiring revision reverse shoulder arthroplasty with bone grafting. No atraumatic catastrophic failures occurred due to component loosening. This study suggests that using angled humeral head bone grafting is a good solution for version correction in extreme posterior glenoid bone loss. Significant improvements are reported in range of motion, pain, and subjective functional scores, with excellent graft incorporation rates and a low complication profile at early follow-up. Further work should focus on gathering higher levels of evidence, detailed radiographic analyses, and exploring humeral head bone grafting for other indications.

Comparison of rostral facet joint violations in robotic- and navigation-assisted pedicle screw placement for adult lumbar spine instrumentation

BACKGROUND CONTEXTFacet joint violation by pedicle screws may lead to adjacent-segment disease and postoperative pain. Previous studies have reported the incidence of rostral facet joint violation using various pedicle screw insertion techniques. However, the incidence of facet joint violations with robotic guidance has not been determined. PURPOSETo investigate and compare the incidence of rostral facet joint violation by pedicle screws under robotic guidance and computerized tomography (CT) navigation guidance. STUDY DESIGN/SETTINGRetrospective matched cohort. PATIENT SAMPLEAll patients who underwent robotic-assisted lumbar fusion at a major spine center up until 2023 were retrospectively identified and matched 1:3 to patients undergoing CT navigation guidance based by on age, sex, rostral vertebral level, and length of construct. Inclusion criteria consisted of age greater than 18 years, bilateral pedicle screw fixation, and presence of a postoperative CT scan of the lumbar spine or abdomen/pelvis at any point in the post-operative period. OUTCOME MEASURESRostral facet joint violations. METHODSDescriptive statistics were used to compare cohorts: frequencies, chi-squared analysis for categorical variables, and t-test for continuous variables. RESULTSA total of 408 rostral pedicle screws were implanted in 204 patients (Robot: 102; Navigation: 306). Overall, 13 (12.3%) rostral facet joint violations were observed in the robot cohort and 75 (24.5%) in the navigation cohort (p=.01). Specifically, fewer robotic violations were observed at the L2 (3.5% vs. 32.1%, p=.003) and L3 levels (3.9% vs. 18.1%, p=.08) compared to navigation. No difference was observed at L4 and L5. Bilateral violations are significantly reduced with robotic approaches (5.3% vs. 14.4%, p=.03). Lastly, more facet joint violations were observed during open approaches (robot: 18.8%, navigation: 27.3%) than percutaneous approaches (robot: 11.6%, navigation: 7.1%) in both groups (p<.001). The rate of L4 facet violations was 18.8% in the robotic cohort and 27.3% in the navigation cohort. The rate of L5 facet violations was 31.3% in the robotic cohort and 29.2% in the navigation cohort. CONCLUSIONSUse of robotic assistance in lumbar pedicle screws significantly reduced the rate of rostral facet joint violations compared to navigation guidance at L2 and L3 levels, but not at L4 and L5, with facet violations approaching nearly one-third of the patients at L5 screws. Rostral facet violations can play a significant role in adjacent segment degeneration and disease. Technical factors and trajectory issues likely play a role and addressing these components should minimize unintended facet violation and proximal adding on.

Differential Impact of Subcutaneous and Visceral Fat on Bone Changes after Gastrectomy.

Osteoporosis and fragility fractures are crucial musculoskeletal complications in long-term survivors of gastric cancer. However, the relationship between changes in body composition after gastrectomy and bone loss has not been investigated. Therefore, this study aimed to explore whether computed tomography (CT)-derived body composition parameters are associated with bone loss after gastrectomy in patients with gastric cancer. We retrospectively reviewed medical records and abdomen CT scans of patients who underwent gastrectomy at Yonsei University Severance Hospital between 2009 and 2018. Patients with non-metastatic gastric adenocarcinoma and preoperative and postoperative non-contrast CT scans were analyzed. Section area of skeletal muscle (SMA), visceral fat (VFA), and subcutaneous fat (SFA) were assessed using semi-automatic segmentation software. Changes in trabecular bone attenuation of L1 mid-vertebra level (L1 Hounsfield units [HU]) were measured. Fifty-seven patients (mean age, 65.5±10.6; 70.2% males) were analyzed, and the median duration was 31 months. Fortyseven patients (82.5%) lost weight after gastrectomy. Baseline SMA and VFA did not differ between the bone loss and preserved groups; however, baseline SFA was significantly higher in the bone preserved group than in the bone loss group (P=0.020). In a multivariable linear regression model adjusted for confounding factors, one standard deviation higher VFA at baseline was associated with greater annualized L1 HU loss (%) (P=0.034). However, higher preoperative SFA was associated with protection against bone loss after gastrectomy (P=0.025). Higher preoperative SFA exhibited a protective effect against bone loss after gastrectomy in patients with non-metastatic gastric cancer, whereas VFA exhibited a negative effect.