Preoperative Planning Research Articles

High accuracy of component positioning and restoration of lower limb alignment using robotic medial unicompartmental knee arthroplasty.

Unicondylar arthroplasty was performed using robotic medial unicompartmental knee arthroplasty (R-mUKA) and gap-balancing instrumentation. Our hypothesis was that robotic unicondylar knee arthroplasty accurately restores component positioning and lower limb alignment when compared to preoperative planning with actual implantation throughout the range of knee motion due to proper knee balancing. Data were collected prospectively and were analysed for patients undergoing RM-UKA. A cemented UKA was implanted using the MAKO® robotic system. Lower limb alignment at 0°, 30°, 45°, 60° and 90° of flexion was recorded of the native knee, with the trial components in place and finally after component implantation. A spacer according to the femorotibial gap was introduced and the alignment was measured. The position of the final component was planned based on three-dimensional computed tomography images before making the bone cuts. The positioning of the femoral and tibial components was analysed in all three planes. A total of 52 patients were included (mean age 66.3 ± 6.7 years; 34 males, 18 females). The difference in femoral component position after planning and final implantation was 0.04° ± 0.58° more valgus in the coronal plane (p = 0.326) and 0.6° ± 1.4° more flexion relative to the sagittal plane (p = 0.034). The tibial component was placed in the coronal plane in 0.3° ± 0.8° of more varus (p = 0.113) and in the sagittal plane in 0.6° ± 1.2° of more posterior tibial slope (p = 0.001). Lower limb alignment of the native knee in extension was 5.8° ± 2.6° of varus and changed to 3° ± 2.1° varus after UKA (p ≤ 0.01). R-mUKA helps to achieve the target of alignment and component position without any significant differences to the planning. Ligament balancing causes non-significant changes in component position. It allows optimal component position even for off-the-shelf implants respecting the patient's specific anatomy. II.

Accuracy of robotic arm-assisted versus computed tomography-based navigation in total hip arthroplasty using the direct anterior approach: a retrospective study

BackgroundA robotic arm-assisted and a computed tomography (CT)- based navigation system have been reported to improve the accuracy of component positioning in total hip arthroplasty (THA). However, no study has compared robotic arm-assisted THA (rTHA) to CT-based navigated THA (nTHA) concerning accuracy of cup placement and acetabular fractures using the direct anterior approach (DAA). This study aimed to compare the accuracy of cup placement and the presence of intraoperative acetabular fractures between rTHA and nTHA using DAA in the supine position.MethodsWe retrospectively investigated 209 hips of 188 patients who underwent rTHA or nTHA using DAA (rTHA using the Mako system: 85 hips of 79 patients; nTHA: 124 hips of 109 patients). After propensity score matching for age and sex, each group consisted of 73 hips. We evaluated clinical and radiographic outcomes, comparing postoperative cup orientation and position, measured using a three-dimensional templating software, to preoperative CT planning. Additionally, we investigated the prevalence of occult acetabular fracture.ResultsClinical outcomes were not significantly different between the groups at 1 year postoperatively. The mean absolute error of cup orientation was significantly smaller in the rTHA group than in nTHA (inclination: 1.4° ± 1.2° vs. 2.7° ± 2.2°, respectively; p = 0.0001, anteversion: 1.5° ± 1.3° vs. 2.2° ± 1.7°, respectively; p = 0.007). The cases within an absolute error of 5 degrees in both RI and RA were significantly higher in the rTHA (97.3%) than in nTHA group (82.2%) (p = 0.003). The absolute error of the cup position was not significantly different between the two groups. The prevalence of occult acetabular fracture did not differ significantly between the two groups (rTHA: n = 0 [0%] vs. nTHA: n = 1 [1.4%]).ConclusionCup placement using DAA in the supine position in rTHA was more accurate with fewer outliers compared to nTHA. Therefore, rTHA performed via DAA in a supine position would be useful for accurate cup placement.

Vascular complications during appendectomy: severe adhesion of the appendix to the right iliac artery: a case report

IntroductionAppendicitis is a common cause of acute abdomen. Rarely, it may form adhesions to nearby structures, complicating surgeries, especially when involving vascular structures such as the internal iliac artery, potentially causing severe intraoperative hemorrhage.Case presentationA 65-year-old Middle Eastern male presented with abdominal pain and anorexia for 5 days. Examination and imaging confirmed acute appendicitis with complications. Additionally, a large pelvic mass was noted. During surgery, severe bleeding was encountered due to an adhesion between the appendix and the right internal iliac artery, managed by ligating the artery. The patient recovered well and was discharged in stable condition. Histopathology confirmed the diagnosis.ConclusionThis case highlights a rare vascular complication of appendectomy due to abnormal adhesions between the appendix and the internal iliac artery, associated with a large pelvic mass. This study emphasizes the need for thorough preoperative evaluation and careful surgical planning in patients with unusual anatomical variations or specific underlying conditions such as neurofibromatosis. Early recognition and strategic management of vascular adhesions are essential to optimize patient outcomes in appendectomies complicated by such rare scenarios.

Exploring Anatomical Variations in the Bony Architecture of the Greater Palatine Canal in Dry Bones.

Introduction The greater palatine canal (GPC) holds significant clinical importance due to its role in providing access to the branches of the maxillary division of the trigeminal nerve. Anatomical variations within this posterior maxillary region can complicate the surgical anatomy, making the identification of vital structures challenging. Therefore, a thorough understanding of both normal anatomy and common anatomical variations of the GPC is essential to minimize perioperative complications during surgical procedures.This study aims to investigate the bony architecture of the GPC in dry bones to identify anatomical variations and address significant lacunae in our current understanding of this structure. Despite its impact on the management of various dental and surgical procedures, there remains a limited and sometimes inconsistent knowledge of the normal and variant anatomy of the GPC.Existing literature often lacks comprehensive detail regarding the range of anatomical variations and their implications for surgical approaches. By systematically documenting these variations, this study aims to bridge these gaps in knowledge, justify the need for continued research in this area, and highlight its potential clinical implications. Materials and methods In total, 30 dried and intact adult skull specimens were selected, consisting of 19 males (63.3%) and 11 females (36.7%). The selection criteria included an intact hard palate with fully erupted third molars and an intact lateral nasal wall on both sides. The presence of erupted third molars was used to assess the degree of bone resorption, ensuring that only specimens with minimal bone loss were included. The exclusion criteria ruled out specimens with major craniofacial deformities, excessive bone resorption, and signs of advanced age. The bony walls of the GPC were observed by passing a black wire made of rubber material with a consistent diameter (approximately 5 mm), allowing us to qualitatively assess the bore of the canal. Results In four out of 30 specimens (13.3%), significant variations were noted in the bony medial wall of the GPC. Of these, three specimens were male (75%) and one was female (25%). These variations have been categorized into four distinct types for clarity and analysis. Type 1, in a male specimen, showed a deficiency in the lower segment of the bony medial wall of the left GPC above the greater palatine foramen. Type 2, in a male specimen, had a small bar of bone in the left GPC midway between the foramen and the pterygopalatine fossa. Type 3, in a female specimen, exhibited a small bar of bone above the greater palatine foramen on the right side, with no wall above it. Type 4, in a male specimen, displayed a bar of bone above the greater palatine foramen on the right side, with the medial wall completely absent on the left side. Conclusion The study identified anatomical variations in the bony architecture of the GPCbased on dry bone specimens. While these findings offer insights into potential variations that could affect surgical procedures, their clinical implications need validation through patient-based studies. Understanding these variations is crucial for improving preoperative planning and reducing surgical risks, but recommendations should be cautious given the limited sample size. Further research with larger samples and clinical validation is needed to fully understand the embryological basis and potential impact on surgical practice.

Automated Preoperative Planning Algorithm for Mandibular Angle Osteotomy Based on Anatomical Landmarks Detection: A Retrospective Study.

The aim of the study was to develop and evaluate an automated preoperative planning algorithm based on anatomical landmark point recognition for enhancing the efficiency and intelligence of preoperative planning for mandibular angle osteotomy. A retrospective cohort of 34 patients underwent preoperative planning with this algorithm. The present algorithm was developed using a method based on anatomical marker point recognition. The efficiency, symmetry, and safety of the automated preoperative planning and esthetics were statistically analyzed by paired t test and χ2 test. The results showed that the automated planning algorithm was able to achieve a great improvement in preoperative planning efficiency as well as safety and symmetry. A prospective case report of 2 patients is then reported, illustrating the safety and esthetics of the algorithm with 1-year postoperative follow-up and postoperative esthetic scores. This algorithm can help to improve the efficiency of preoperative planning for surgeons while ensuring safety and esthetics and can be further applied to other craniomaxillofacial personalized design surgeries in the preoperative design in the future.

Novel imaging techniques for tumor margin detection in basal cell carcinoma: a systematic scoping review of FDA and EMA-approved imaging modalities.

Mohs micrographic surgery (MMS) is the gold standard for removing basal cell carcinomas (BCCs) due to its ability to guarantee 100% margin evaluation through frozen section histopathology, offering the highest cure rate among current treatments. However, noninvasive imaging technologies have emerged as promising alternatives to clinical assessment for defining presurgical margins. This systematic scoping review examines the efficacy of these imaging modalities, focusing on those approved for clinical use by the United States Food and Drug Administration (FDA) or the European Medicines Agency (EMA). A systematic search of EMBASE, Scopus, PubMed, and the Cochrane Public Library databases identified 11 relevant studies out of 2123 records, encompassing 644 lesions across five imaging techniques. The findings suggest that dermoscopy, high-frequency ultrasound (HFUS), optical coherence tomography (OCT), line-field optical coherence tomography (LC-OCT), and reflectance confocal microscopy (RCM) show potential in detecting BCC margins, which could enhance MMS by providing better preoperative planning, informing patients of expected defect size, aiding in reconstruction decisions, and reducing overall procedure costs. This review discusses the benefits and limitations of each technique, offering insights into how these innovations could influence the future of BCC management. Emerging imaging techniques could enhance MMS by improving BCC margin assessment and reducing costs. Their adoption will depend on price and ease of use.

Preoperative Planning for Shoulder Arthroplasty is Feasible with Computed Tomography at Lower-Than-Conventional Radiation Doses

Computed tomography (CT) offers a detailed assessment of the shoulder for preoperative shoulder arthroplasty planning; however, this technique exposes the patient to ionizing radiation. The purpose of this study was to prospectively evaluate the practicality of reducing the CT radiation dose compared to conventional dose levels for manual and preoperative planning software measurements for shoulder arthroplasty. A total of 10 shoulder CT examinations were performed for preoperative planning purposes on a dual x-ray source CT scanner. A specialized dose-split scan technique was utilized to reconstruct CT images corresponding to 100%, 70%, and 30% radiation dose relative to our institution's standard of care imaging protocol. Glenoid version, inclination, and humeral head subluxation were measured manually by three authors and by commercially available software platforms. These measurements were analyzed for agreement between the 100%, 70%, and 30% dose levels for each patient. Tolerances of 5° of glenoid version, 5° of glenoid inclination, and 10% humeral head subluxation were used as equivalent for preoperative planning. Automated measurements of 70% dose images were within 5° of version, 5° of inclination, and 10% subluxation in 95.0% of cases. Manual measurements of 70% RD images were within 5° of version for 90.0% of cases, 5° of inclination in 86.7% of cases, and 10% subluxation in 100% of cases. Automated measurements from the 30% dose images were within 5° of version, 5° of inclination, and 10% subluxation for 100% of cases. Manual measurements from the 30% dose images were within 5° of version for 86.7% of cases, 5° of inclination in 76.7% of cases, and 10% subluxation in 100% of cases. The mean absolute difference in software measurement of glenoid version (p = 0.96), glenoid inclination (p = 0.64), or humeral head subluxation (p = 0.09) or in aggregated manual mean absolute difference of version (p = 0.22), inclination (p = 0.31), or humeral head subluxation (p = 0.56) was not significant. Good to excellent reliability was determined by interclass correlation coefficients among the manual observers and automatic software platforms for measurements at all doses (P<0.001) CONCLUSIONS: The results indicate that both preoperative planning software platforms and human observers produced similar measurements of glenoid version, inclination, and humeral head subluxation from reduced-dose images compared to standard of care doses. By implementing reduced dose techniques in preoperative shoulder CT, the potential risks associated with radiation exposure could be reduced for patients undergoing shoulder arthroplasty.

Application of Mixed Reality Technology in the Planning of PCNL for Special Types of Complex Upper Urinary Stones: A Pilot Study

ObjectiveTo evaluate the application of Mixed Reality technology in the planning of ultrasound-guided PCNL for special types of complex upper urinary stones. MethodsClinical data of 15 patients with complex upper urinary stones undergoing ultrasound-guided PCNL were analysed which included pelvic ectopic kidney, horseshoe kidney, spinal deformity, and transplant kidney. Based on preoperative CTU data, digital three-dimensional reconstruction is performed, and AI mixed reality is used to project three-dimensional images in real space. This facilitates preoperative design and planning. The consistency rate of target calyx and channel numbers, stone free rate, total operative time, percutaneous renal access establish time, decrease in hemoglobin level, surgical complications, and postoperative hospital stay are analyzed. ResultsAll patients underwent preoperative planning using mixed reality and successfully completed PCNL. Based on the preoperative planning, we utilized S-PCNL alone or combined with Needle-perc or antegrade/retrograde FURS. The consistency rate between preoperative planning and intraoperative completion was 87.6%. The stone free rate was 80%. The average time for establishing the main tract was 2.3±0.3 minutes, and the average total operative time was 61.5±12.2 minutes. The mean decrease in hemoglobin level was 9.6±1.2 g/L, and the average postoperative hospital stay was 4.6±0.5 days. There were no occurrences of Clavien-Dindo grade≥II complications. ConclusionPreoperative quantification and analysis of imaging data through mixed reality enable three-dimensional visualization and facilitate surgical plans, and effectively avoid the risks of surrounding organ injury in these special urinary stones cases, make complex surgeries smoother and more controllable.

Total Hip Arthroplasty in Hip Osteoarthritis with Subtrochanteric Localized Periosteal Thickening: Preoperative Planning Using Finite Element Analysis to Determine the Optimal Stem Length

Background: Owing to the risk of atypical femoral fractures, total hip arthroplasty presents unique challenges for patients with ipsilateral osteoarthritis and localized periosteal thickening in the femoral subtrochanteric region. Stem length selection is critical for minimizing stress concentration in the thickened cortex to avoid such fractures. Herein, we report the case of a 78-year-old woman with ipsilateral hip osteoarthritis and localized subtrochanteric periosteal thickening. Methods: Preoperative planning included a finite element analysis to assess the stress distribution across various stem lengths. A simulation was conducted to determine the optimal stem length to span the cortical thickening and reduce the risk of postoperative complications. Results: The finite element analysis indicated that a stem length of &gt;150 mm was required to effectively reduce the stress at the site of cortical thickening. A 175 mm stem was selected for total hip arthroplasty, which provided a favorable stress distribution and avoided the risk of stress concentration. Conclusions: In cases of ipsilateral osteoarthritis with localized subtrochanteric periosteal thickening, finite element analysis can be valuable for preoperative planning to determine the optimal stem length, thereby reducing the risk of atypical femoral fractures. Further studies with multiple cases are recommended to validate these findings and improve surgical outcomes.

Adaptation of virtual surgical planning to midface reconstruction with intraoperative navigation: “navigation mediated midface reconstruction”

ObjectiveThe production of three dimensional models and materials according to preoperative virtual surgical planning is a time consuming process and causes high costs. We aimed to demonstrate the navigation mediated reconstruction of the patients who underwent the removal of tumoral mass in midfacial region according to their preoperatively prepared surgical plannings. Study DesignPatients who underwent the removal of tumoral mass and reconstruction in their midfacial region were included in the study. Virtual surgical planning was performed by the mirror imaging of unaffected side of maxillofacial bones. New created models were converted to DICOM (Digital Imaging and Communications in Medicine) data to use in the navigation system. Histogram analysis was performed to reveal the compatibility of navigation mediated reconstruction with preoperative virtual surgical planning. ResultsReconstruction of orbital floor was achieved in all of the cases. Histogram comparison of the localizations of orbital floor and maxillary walls was calculated at a confidence level of 95 % (p > 0.95) and mean difference was found 0.85 mm; while standard deviation was 3.55 mm. ConclusionWe found that virtually prepared reconstruction of midfacial area can be succesfully adapted to the surgery with the assistance of intraoperative navigation system.

Preoperative 3D Planning and Intraoperative Navigation in Robot-Assisted Laparoscopic Surgery for Complex Pheochromocytoma.

To evaluate the value of preoperative 3D planning and intraoperative navigation in robot-assisted laparoscopic surgery for complex pheochromocytoma. Observational study. Place and Duration of the Study: Department of Urology, The Affiliated Hospital of Hebei University, from July 2022 to July 2023. Sixty patients with complex pheochromocytoma were divided into the study group (n = 30) and the control group (n = 30) according to the treatment method. The study group was treated with robot-assisted laparoscopic surgery, with preoperative 3D printing-based planning, and intraoperative 3D navigation, and the control group underwent conventional retroperitoneal robot-assisted laparoscopic surgery. Surgical-related indicators and intraoperative and postoperative complication rates between the two groups were compared. The operation time, postoperative hospital stay, and drainage tube retention time in the study group were significantly shorter than in the control group (p <0.001), and the intraoperative blood loss in the study group was significantly less than in the control group (p <0.001). The study group exhibited a significantly lower incidence of intraoperative haemodynamic instability (HI), use of vasoactive drugs, and postoperative ICU transfer rate than the control group (p <0.05). The incidence of surgical complications in the study group was significantly lower than in the control group (p = 0.04). The non-recurrence rate in the study and control groups after 1-year follow-up was 96.7% and 90%, respectively (χ2= 2.77, p = 0.10). Robot-assisted surgery, performed through renal surface, has the advantages of less bleeding, shorter surgical time, faster recovery, fewer complications related to chromaffin cell inflammation and postoperative complications, and is safe and effective in treating complex pheochromocytoma. 3D planning and navigation, Robot-assisted surgery, Complex pheochromocytoma.

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.

3D Imaging Reconstruction and Laparoscopic Robotic Surgery Approach to Disseminated Peritoneal Leiomyomatosis

ObjectivesThis video article explores the synergistic approach of 3D imaging reconstruction and laparoscopic robotic surgery for the management of a complex case of disseminated peritoneal leiomyomatosis (1). The primary focus lies in the capability of the reconstruction model to provide diagnostic support to identify fibroids during surgical procedures, potentially enhancing surgical precision, reducing operating times, minimizing uterine incisions, and limiting blood loss. 3D imaging reconstruction techniques were used to facilitate the identification of multiple parasitic and non-serosal myomas, which is particularly challenging when operating with a robotic surgical platform that lacks haptic feedback. SettingTertiary referral center. ParticipantsA case report design was employed, focusing on a 43-year-old nulliparous infertile woman with multiple symptomatic uterine myomas. Our institution has made a further diagnosis of disseminated peritoneal leiomyomatosis(4-5). InterventionsDue to the widespread nature of peritoneal leiomyomatosis and numerous uterine fibroids, robotic surgery was considered a preferable option based on our experience to operate within confined anatomical spaces. 3D imaging reconstruction technology was utilized for preoperative and intraoperative planning, enabling precise determination of the fibroids' location, size, and volume obtained through MRI imaging. Real-time 3D imaging guided rapid myoma localization and surgical strategy adjustment (2-3). The procedure resulted in the removal of 15 fibroids, with minimal blood loss (250 mL) and a total operative time of 120 minutes. Multilayer running hysterorraphy was performed using a barbed monofilament suture to ensure effective hemostasis, incorporating serosal introflection to reduce the risk of post-operative adhesion development. ConclusionsThe combined approach of 3D imaging reconstruction and laparoscopic robotic surgery holds significant potential for the management of disseminated peritoneal leiomyomatosis. This approach can overcome some robotic surgery limitations, particularly the absence of haptic feedback, providing accurate preoperative planning and real-time intraoperative guidance, facilitating efficient fibroid localization, minimizing uterine incisions, and reducing blood loss. Further research is needed to fully evaluate the clinical impact of this promising technology.

Reliability analysis of WBCT-derived 3D models for comparing preoperative and postoperative alignment in total ankle arthroplasty

BackgroundTraditional imaging techniques for total ankle arthroplasty (TAA) evaluation are limited by rotational bias and bone superimposition, highlighting the necessity for more precise assessment methods. The advent of weight-bearing computed tomography (WBCT) generated 3D enhance the visualization of foot and ankle alignment, offering unmatched detail. This study aims to assess the accuracy of preoperative and postoperative measurements in TAA across all three planes using WBCT-generated 3D models. We hypothesize that these models can be reliably used to compare preoperative and postoperative alignment. MethodsFor 81 patients undergoing TAA, preoperative and postoperative WBCT models were created. Measurements included five coronal angles: Alpha, Tibiotalar Surface Angle (TSA), Talar Tilt Angle (TT), Salzmann's 20 degrees Angle (SA), and Talocalcaneal Angle (TCA); three sagittal angles: Beta, Gamma, and Tibiotalar Ratio (TTR); and one axial angle: The Posterior Talar Rotational Angle (PTARA). Two raters evaluated these before and after surgery in two separate sessions. The study then compared preoperative to postoperative measurements, calculating inter-rater and intra-rater reliability. ResultsSignificant changes were observed in three coronal angles (TSA, TT, and SA) and two sagittal angles (Beta and Gamma), with P-values of 0.2, 0.007, 0.019, <0.001, and <0.001, respectively. No significant changes were noted in Alpha, TCA, TTR, and PTARA, with P-values of 0.2, 0.9, 0.2, and 0.6, respectively. Intra-rater and inter-rater reliability scores ranged from 0.885 to 0.97, indicating good to excellent interclass correlation across all planes, both pre-and postoperatively. ConclusionWBCT-generated 3D modeling and image analysis software have enabled a detailed comparison between preoperative alignment and postoperative TAA positioning across coronal, sagittal, and axial planes, revealing significant adjustments in coronal and sagittal alignments. The high reliability and reproducibility of these measurements affirm their value in preoperative planning in improving the accuracy of surgical interventions. Level of evidenceLevel III of evidence

Correlation of Preoperatively Planned Humeral Component Size and Actual Implanted Size: A Retrospective and Prospective Evaluation of Anatomic and Reverse Shoulder Arthroplasty

BackgroundThe aims of the study were to (1) evaluate the correlation of planned humeral component diameter with implanted humeral component diameter for reverse total shoulder arthroplasty (rTSA) and (2) to evaluate the correlation of planned humeral components with executed humeral components for stemless anatomic total shoulder arthroplasty (aTSA). MethodsFour shoulder surgeons participated in two phases of the study. In the retrospective arm, 3 months of TSA and rTSA cases which were completed with preoperative CT-based planning, but without any humeral planning, were re-planned using humeral planning, and the components from the virtual planning compared to the implanted components. In the prospective arm, 3 months of TSA and rTSA cases were prospectively planned by each surgeon. The planned and implanted components were similarly compared. Results97 rTSAs were included (50 retrospective, 48 prospective). In the retrospective analysis, in 60% of cases, the rTSA stem diameter was within one size of the plan; in 84%, it was within two sizes; in 90%, it was within 3 sizes. In the prospective analysis, the rTSA stem diameter was within one size in 73% of cases; in 90% within 2 sizes, and in 94% within 3 sizes (p > 0.05 all comparisons). The cup diameter was always within one size of the plan; it matched in 84% of the retrospective cases and 90% of the prospective cases (p > 0.05). 77 TSA were included (33 retrospective, 44 prospective). For prosthetic head diameter, in the retrospective analysis, it was an exact match in 52% of patients, within one size in 85% and within two sizes in 100%. In the prospective analysis, the diameter was an exact match in 57%, within one size in 86% and within two sizes in 100% (p > 0.05 all comparisons). The thickness of the prosthetic component was a match to the plan in 88% of the retrospective cases and 86% of prospective cases (p > 0.05). ConclusionsFor the utilized planning software and implants, humeral planning for rTSA affords some predictability for stem diameter regardless of whether assessed retrospectively or prospectively, with 84-90% of cases within two diameters of the plan. The inlay humeral cup diameter was an exact match to the plan in 84-90% of cases. For stemless aTSA, the humeral component diameter was an exact match to the plan in 52-57%, but within one size in 85-86% of cases. There were no significant differences if the planning was performed retrospectively or prospectively.

Innovations in 3D printed individualized bone prosthesis materials: revolutionizing orthopedic surgery: a review.

The advent of personalized bone prosthesis materials and their integration into orthopedic surgery has made a profound impact, primarily as a result of the incorporation of three-dimensional (3D) printing technology. By leveraging digital models and additive manufacturing techniques, 3D printing enables the creation of customized, high-precision bone implants tailored to address complex anatomical variabilities and challenging bone defects. In this review, we highlight the significant progress in utilizing 3D printed prostheses across a wide range of orthopedic procedures, including pelvis, hip, knee, foot, ankle, spine surgeries, and bone tumor resections. The integration of 3D printing in preoperative planning, surgical navigation, and postoperative rehabilitation not only enhances treatment outcomes but also reduces surgical risks, accelerates recovery, and optimizes cost-effectiveness. Emphasizing the potential for personalized care and improved patient outcomes, this review underscores the pivotal role of 3D printed bone prosthesis materials in advancing orthopedic practice towards precision, efficiency, and patient-centric solutions. The evolving landscape of 3D printing in orthopedic surgery holds promise for revolutionizing treatment approaches, enhancing surgical outcomes, and ultimately improving the quality of care for orthopedic patients.

Virtual Reality Surgical Planning of a Complex Two-Jaw Defect

Head and neck reconstruction poses challenges requiring stable coverage and optimal appearance and functionality. In complex cases, and beyond the right choice of flap, Virtual Reality (VR) surgical software and preoperative planning, are needed to optimize outcomes. Our patient is a 16-year-old with a history of rhabdomyosarcoma necessitating maxillary-mandibular defect reconstruction. VR-based preoperative planning facilitated the intervention by creating 3D-VR models of facial anatomy and fibula, simulating resection margins, and creating surgical guides for intraoperative use. Our 2-team surgeons opted for a single-staged reconstruction using a vascularized fibula free flap. This case demonstrates successful single-flap reconstruction of a maxillary-mandibular defect, addressing challenges of recipient vessel scarcity, fibrotic scarring, and poor tissue quality. It also underscores the efficacy of a 2-team approach and VR-based preoperative planning in achieving successful outcomes in complex maxillary-mandibular reconstruction. The use of a single fibula flap minimized possible complications and operative time, and the 2-team approach helped by combining the expertise and training of craniofacial and microsurgical trained surgeons. Acknowledging limitations in imaging quality and real-time adaptability, we advocate for continued exploration of VR technologies in enhancing surgical precision in challenging cases.

Management of Rotator Cuff Tears in Severely Osteoporotic Patients

Management of rotator cuff tears (RCT) in osteoporotic patients presents significant challenges for treating clinicians because of compromised bone quality. We present a case series of 2 patients with RCT and severe osteoporosis highlighting the complexities of operative and nonoperative management and underscoring the importance of preoperative optimization and careful surgical planning in this vulnerable population. Patient 1 experienced initial improvement postarthroscopic RCT repair but required revision surgery because of anchor pullout, with eventual conversion to reverse total shoulder arthroplasty. Patient 2 faced intraoperative challenges because of previously undiagnosed osteoporosis, leading to difficulties in securely placing suture anchors, and was referred to the fracture liaison service (FLS) for osteoporosis management postoperatively. A multifaceted approach integrating preoperative optimization, advanced surgical techniques, and postoperative management is advised to improve operative success. Extensive perioperative bone quality assessments and augmentation strategies are warranted, including medication comanagement through an FLS if available. Detailed surgical planning is crucial, focusing on arthroscopic repair technique while considering various anchor factors to mitigate failure including proper placement, design, and pullout analysis. Intraoperative bone augmentation with materials such as calcium phosphate, magnesium phosphate, and polymethyl methacrylate cements significantly improves anchor fixation strength in osteoporotic bone. Consideration of a transosseous approach and potential for conversion to an open procedure is also an option when necessary. This review highlights the unique challenges and potential options available to treating clinicians when managing RCT in osteoporotic patients. Continued research and refinement of emerging treatment strategies are essential to improve outcomes and quality of life in this patient population.

Utility of Risk Analysis Index for Assessing Morbidity in Patients Undergoing Posterior Spinal Fusion for Adult Spinal Deformity

This study investigates the predictive values of the Risk Analysis Index (RAI), the modified 5-item Frailty Index (mFI-5), and advanced age for predicting 30-day extended length of stay (LOS), 30-day complications and readmissions in patients undergoing posterior spinal fusion (PSF) for adult spinal deformity (ASD). A retrospective cohort study was performed using the 2012-2021 ACS NSQIP database. Adults undergoing posterior spinal fusion for ASD were identified using CPT and ICD codes. Using receiver operating characteristic (ROC) and multivariable analyses, we compared the discriminative thresholds and independent associations of RAI, mFI-5, and greater patient age for extended LOS, 30-day complications and readmissions. In this cohort of 3,814 patients, RAI identified 90.7% as Robust, 6.0% as Normal, and 3.3% as Frail/Very Frail, while mFI-5 classified 47.1% as Robust, 37.5% as Normal, and 15.3% as Frail/Very Frail. Multivariate analysis revealed both RAI and mFI-5 as significant predictors of extended LOS for Normal (RAI: p<0.001; mFI-5: p=0.012) and Frail/Very Frail patients (RAI: p<0.001; mFI-5: p=0.002). Additionally, RAI was a significant predictor of 30-day complication risk for Normal patients (p=0.005). Furthermore, mFI-5 was a significant predictor of 30-day readmission among Frail/Very Frail patients (p=0.002). This study highlights the utility of RAI and mFI-5 in predicting extended LOS patients undergoing PSF for ASD. RAI was found to be superior to mFI-5 for predicting 30-day readmissions, while mF-5 was greater for 30-day complications. These findings highlight the importance of incorporating frailty assessments into preoperative surgical planning.

Medial Tibial Condylar Valgus Osteotomy improve clinical outcomes and effectively corrects significant Tibial varus deformities without compromising joint line obliquity or patellar heigh

BackgroundTibial condylar valgus osteotomy (TCVO), or Chiba osteotomy, is a recognized procedure for treating advanced knee osteoarthritis in middle-aged individuals. Although its effectiveness is established, limited literature exists on its outcomes for specific conditions such as post-traumatic deformities, Blount disease (BD), and Pagoda-like proximal tibia varus deformities. HypothesisWe hypothesized that TCVO could improve both clinical and radiographic outcomes in patients with severe varus deformities, correcting lower-limb variances while preserving joint line obliquity (JLO) and patellar height in substantial varus deformities. Patients and methodsThis study included 33 patients who underwent TCVO, with etiologies including post-traumatic (26 patients, 78.8%), Blount disease (4 patients, 12.1%), and Pagoda deformities (3 patients, 9.1%). The average age was 32.5 years (standard deviation = 12.8 years). Techniques for deformity correction varied, including Patient Specific Instrumentation (PSI) for 10 patients (30.3%) and locking plate fixation for 13 patients (39.4%). We assessed several radiological parameters such as hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), Caton-Deschamps index (CDI), and proximal posterior tibial angle (PPTA). Patient-reported outcomes, including the Knee injury and Osteoarthritis Outcome Score (KOOS) and simple knee value (SKV), were recorded both pre-operatively and two years post-operatively. ResultsStatistically significant improvements were observed in clinical scores and alignment changes two years post-operatively, including increases in HKA (from 166.1 to 178.4, p < .0001) and MPTA (from 72.4 to 85.1, p < .0001), and a decrease in JLO (from 9.8 to 3.2, p < .0001). No significant changes were noted in JLCA, PPTA, and CDI, with the patellar height remaining stable post-operatively. The achieved corrections closely matched the pre-operative plans. ConclusionTCVO offers significant improvements in radiological and clinical parameters for patients with substantial tibial varus deformities, effectively maintaining JLO and patellar height. Optimal outcomes from TCVO are dependent on careful patient selection and precise execution of surgical techniques. Level of evidenceIII.