Use Of Virtual Surgical Planning Research Articles

Effectiveness of Virtual Surgical Planning and Three-Dimensional Anatomical Models in Radiological Reconstruction of Center of Rotation and Pelvic Brim in Patients with Anterior Column Defects Requiring Revision Hip Arthroplasty

Background: The aim of this study was to show that virtual surgical planning (VSP) and printed anatomical models support the reconstruction of the center of rotation (COR) and pelvic BRIM during revision hip surgery using a dual-mobility revision cup system in patients with anterior pelvic column damage and soft tissue envelope deficiency. Methods: Patients with anterior pelvic column damage and soft tissue envelope deficiency underwent revision hip arthroplasty. Virtual planning included assessment of bone segmentation, positioning of the cementless revision cup while maintaining the COR, and the assumed inclination and anteversion angles. Results: The diameter of the planned revision cups was 65.5 ± 2.1 mm, and the diameter of the revision cups used was 65.3 ± 2.1 mm. The difference in COR position in the horizontal axis was 7.8 ± 9.3 mm, in the vertical axis was 4.3 ± 5.9 mm, and in the axial plane was 1.6 ± 3.3 mm. The differences in inclination angle and in the anteversion angle were 12.4° and 8.7°, respectively. Conclusions: The use of VSP and 3D models supports the process of performing RHA surgery in patients with damage to the anterior pelvic column and soft tissue envelope deficiency.

Virtual surgical planning in tripod zygomatico-maxillary complex fractures: A prospective comparison between two different strategies

Multifragmentary and displaced zygomaticomaxillary complex (ZMC) fractures are often a challenge for the maxillofacial surgeon. The aim of this study was to evaluate the improved performance in the management of patients with tripod fracture of the orbito-zygomaticomaxillary complex, using two different methods of virtual surgical planning — virtual reduction and mirroring — compared with traditional management. A cohort of 60 patients was selected and divided into three groups, each consisting of 20 individuals. Patients in the first group were managed using the virtual reduction method, those in the second group using the mirroring method, and those in the third group using a traditional surgical approach. Having achieved virtual fracture reduction, a stereolithographic model was printed, on which preplating of the plates was performed. The results showed that virtual reduction was the most accurate in absolute terms, with a mean discrepancy in juxtaposition of the preoperative and postoperative CT images of 0.175 mm (SD ± 0.147), compared with 0.403 (SD ± 0.166) for the mirror method (and traditional method (0.875, SD ± 0.112; p > 0.0001). The average surgical time for virtual reduction (89.5 min) was faster than for mirroring (94.25 min) and for the traditional approach (96.75 min). In conclusion, the use of virtual surgical planning allows greater intraoperative accuracy, reduced surgical time, and reduced postoperative complications compared with traditional surgery. Of the two methods, virtual reduction performed best for the outcomes decribed.

Tips to Virtually Plan Your Free Scapula Flap

Summary: The use of virtual surgical planning (VSP) and computer-aided design and manufacturing to assist in osseous reconstruction has become the standard of care in head and neck reconstruction. The use of the free fibula flap with VSP remains the most common flap for osseous reconstruction, and as such, it is well described in the published literature. The scapular free flap (SFF) based on the angular branch has not yet garnered the same attention. The popularity of the SFF osseus head and neck reconstruction is increasing due to the flaps’ inherently different properties and indications it can fulfill; the natural curvature of the bone, the reduced incidence of atheroscelerosis in the donor vessels and the earlier postoperative mobilization of the patient. In the preoperative planning process, the SFF presents several unique challenges and considerations that differ from the free fibula flap. It is important for surgeons already using, or considering using the SFF, that VSP is used correctly to achieve optimal outcomes. The authors aim to describe and clarify aspects of VSP use in SFF reconstruction in the head and neck area with a specific focus on: (1) The perforator-like vascular anatomy of the scapula; (2) How to maximize the shape of the scapula to minimize osteotomies; (3) Fine-tuning of scapula osteotomies on side table; (4) How to plan cutting guide placement and fit on the scapula. The authors hope that this article will help reconstructive microsurgeons plan and perform the SFF in conjunction with VSP.

Split-Calvarial Bone Graft for a Large Calvarial Defect: Revealing Hidden Contours Through Virtual Surgery Planning

Virtual surgical planning (VSP) stands as a novel advancement in craniofacial surgery. Since its inception, VSP has had the ability to improve accuracy and consistency in craniofacial surgery. The current case report describes the use of VSP in the context of a pediatric growing skull fracture and large calvarial defect requiring autologous reconstruction. Emphasis is placed on patient-specific osteotomy design and cutting guide design to decrease risk and optimize surgical outcomes. This case report illustrates a unique application of VSP in craniofacial surgery.

Virtual Surgical Planning for Point-of-Care Manufacturing

Two factors motivating the achievement of safe and effective Point-of-Care Manufacturing (POCM) are (1) to provide personalized medical devices to patients with short treatment windows (e.g., trauma, advanced stage cancer) and (2) to ensure that those devices improve outcomes and reduce revision surgery rates. In-hospital use of Virtual Surgical Planning (VSP) now commonly includes the production of surgical models and procedure guides (e.g., cutting, drilling, or placement guides and tool jigs). As this technology becomes widely available, we envision the FDA approving VSP software with tools for personalized, implantable, medical device design and POCM. Indeed, VSP for local optimization of device shape (external surfaces and internal pore geometry), placement (anatomical location), materials (via interactive simulation of post-operative device performance), and the fabrication process engineering plan can be executed in real time. This is nothing short of a paradigm shift from manual personalization of off-the-shelf devices or the factory-based fabrication of personalized medical devices. As an example of this new paradigm, we present here a hypothetical VSP pathway for the design and POCM of personalized mandibular graft fixation devices where optimized performance avoids both stress shielding-induced bone loss as well as stress concentration-induced device failure.

Innovations with the scapula and subscapular system for head and neck microvascular reconstruction

Microvascular free flap reconstruction based on the subscapular system is an established and versatile method of reconstructing complex head and neck defects. Since the first published description in the mid-1980s, advances have been made to the harvest technique, positioning, use of virtual surgical planning, and endosseous implants. Here, the most recent literature is reviewed for innovations related to the subscapular system. Microvascular head and neck surgeon preferences related to the subscapular system are surveyed and discussed. The concordance between virtual surgical plans using scapula cutting guides and pre-contoured plates with the postoperative result is assessed, and novel applications of the scapula free flap are presented. Subscapular system free flaps are an established and essential component of the reconstructive armamentarium for head and neck defects with minimal limitations and low donor site morbidity.

Prosthetic rehabilitation in patients with jaw reconstruction by fibula free flap: A systematic review

This systematic review aimed to evaluate the dental prosthetic rehabilitation (DPR) in patients after jaw reconstruction with fibula free flap. Four databases were searched from January 2000 to January 2023. Of the 2507 studies identified, 36 observational studies were included. Cancer was the most common surgical indications for jawbone resection with 58.3 % of cases followed by benign tumours which representing 24 %. The DPR rate was estimated at 51.6 % across the studies (ranging from 38 % to 55 % depending on the benign or malignant nature of the tumors). Implant-supported prostheses represented 58.9 % of cases of which 66.9 % were fixed and 33.1 % were implant-stabilized overdentures. Virtual surgical planning (VSP) was used in 20 % of studies and aimed to improve the position of the grafted fibula, quality, and aesthetics of DPR and to decrease ischemia and the operating time. One in two authors performed DPR 12 months after jaw reconstruction. If implant survival rate reached 93 % in non-irradiated fibula, it fell to 38 %, 55 %, and 77 % if implantation occurred in the 12, 17, and 24 months after radiotherapy, respectively. Various parameters should be better investigated in further studies including the typology of the prostheses (implant-supported vs removable), the use of VSP, and the optimal time for DPR taking into account the characteristics of the tumor, the size of bone defect, and the need for external irradiation therapy

Evolution of Medical Modeling and 3D Printing in Microvascular Midface Reconstruction: Literature Review and Experience at MD Anderson Cancer Center.

Reconstruction of the midface represents a challenge for reconstructive microsurgeons given the formidable task of restoring both aesthetics and functionality. In particular, preservation of proper globe positioning and maintaining normal vision are as important as restoring the proper projection of the midface and enabling a patient to speak and eat as normally as possible. The introduction of virtual surgical planning (VSP) and medical modeling has revolutionized bony reconstruction of the craniofacial skeleton; however, the overwhelming majority of studies have focused on mandibular reconstruction. Here, we introduce some novel advances in utilizing VSP for bony reconstruction of the midface. The present review aims (1) to provide a review of the literature on the use of VSP in midface reconstruction and (2) to provide some insights from the authors' early experience.

Virtual Surgical Planning in Craniosynostosis Reduces Operative Time and Length of Stay for Cranial Vault Remodeling.

Cranial vault remodeling (CVR) with and without frontal orbital advancement remodels the skull in craniosynostosis. Virtual surgical planning (VSP) for preoperative planning has been previously shown to be effective in CVR. In this study, the authors aimed to evaluate the impact of VSP on operative and perioperative efficiency for craniosynostosis surgery. A retrospective chart review was conducted of patients with craniosynostosis who underwent CVR. Patient demographics, perioperative variables, use of VSP, and complications were obtained. Perioperative variables collected include operative time and length of stay. An independent t test was used to compare variables from patients who had surgery with VSP and patients who did not. Records were available for 126 patients with craniosynostosis who underwent CVR of whom 79 (62.7%) utilized VSP. There was no difference in average age at surgery (9.3±5.7mo versus 13.2±31.1mo, P =0.39). Surgeries planned using VSP demonstrated a decreased operative time of 1.3 hours (3.7±1.1 versus 5.0±1.1h, P <0.001) and a shorter length of stay (3.9±1.3 versus 4.6±1.7d, P =0.01). There were no differences in complication rates of dehiscence, infection, returns to the operating room, or 30-day readmission. These trends were similar among patients who underwent fronto-orbital advancement in addition to CVR. Virtual surgical planning was associated with decreased operative time and length of stay for patients with craniosynostosis and comparable complication rates. Virtual surgical planning is an effective tool for reducing anesthetic exposure time.

Utilizing Virtual Surgical Planning and Patient-Specific Cutting Guides in Microtia Repair with Autologous Costal Cartilage Graft.

Virtual surgical planning (VSP) has been applied to many aspects of head and neck reconstruction. The authors describe the use of VSP to create auricular templates in addition to cartilage cutting and suturing guides for microtia repair in 2 patients with unilateral and bilateral grade 3 microtia. Both patients had satisfactory aesthetic results. This technique allows for increased precision, may decrease operative time, and has good cosmetic outcomes.

Virtual Surgical Planning of Superior Orbital Rim Fractures in Calvarial and Maxillofacial Trauma

Superior orbital rim fractures are challenging fractures as they often concomitantly occur with additional calvaria fractures. Virtual surgical planning (VSP) has been underutilized in this area of craniomaxillofacial trauma for reconstruction. The purpose of this study is to qualitatively describe the use of VSP and anatomically perfected stereolithic models in treatment of superior orbital rim fractures in combined neurosurgery/oral and maxillofacial surgery cases. This study is a retrospective case series of subjects who were treated at the Massachusetts General Hospital (July 2022 to November 2022). Inclusion criteria include subjects who had both calvaria and maxillofacial injuries requiring concurrent operative intervention on their superior orbital rim fractures and the use of VSP. Not applicable. The outcome variable of interest is the difference in the planned position of the orbital rim repair compared to the actual position achieved. None. Heat map analysis was used to compare the difference in the planned position versus the actual position achieved. There were six orbits (five subjects, mean age 33.8±21.49years) that met the criteria. The mean difference in planned versus actual orbital volume achieved was 2.52±2.48cm3. The superimposition of the postoperative scan to the planned simulation revealed 84%±3.27% of the voxel surface was within+2 and -2millimeters of its planned position. This study has demonstrated the use of VSP in combined neurosurgery and oral and maxillofacial surgery procedures in the fixation of superior orbital rim fractures. This case series highlights that the postoperative position achieved in the six orbits was within 84% of the planned position.

Craniomaxillofacial Trauma: The Past, Present and the Future.

Reconstruction of facial trauma has seen a significant evolutionary leap in the last 100 years. The current surgical management of facial fractures was made possible by the efforts and creativity of pioneer surgeons, advances in anatomic understanding, and the continued development of biomaterials and imaging technologies. Virtual surgical planning (VSP) and 3-dimensional printing (3DP) are being incorporated into the management of acute facial trauma. The integration of this technology at the point of care is rapidly expanding globally. This article reviews the history of the management of craniomaxillofacial trauma, current practices, and future directions. The use of VSP and 3DP in facial trauma care is highlighted with a description of EPPOCRATIS, a rapid point-of-care process incorporating VSP and 3DP at the trauma center.

Surgical cutting guide and single plate fixation for intraoral vertical ramus osteotomy

With the advancement of digital technology over the last few decades, the use of virtual surgical planning and fabrication of surgical guides have tremendously improved the outcomes of various maxillofacial surgical procedures. The intraoral vertical ramus osteotomy (IVRO) is an orthognathic surgical procedure largely employed for mandibular setback in correcting dentofacial deformities. This study describes the design and application of a surgical cutting guide for IVRO. The guide can also be used to facilitate the placement of miniplate fixation. The initial experience at the authors’ centre suggests that the guide has allowed the osteotomy to be performed with increased precision and confidence. Furthermore, the use of miniplate fixation decreased the period of maxillomandibular fixation. However, a larger series is required to evaluate the utility of this system more thoroughly.

Point-of-Care Virtual Surgical Planning and 3D Printing in Oral and Cranio-Maxillofacial Surgery: A Narrative Review.

This paper provides an overview on the use of virtual surgical planning (VSP) and point-of-care 3D printing (POC 3DP) in oral and cranio-maxillofacial (CMF) surgery based on a literature review. The authors searched PubMed, Web of Science, and Embase to find papers published between January 2015 and February 2022 in English, which describe human applications of POC 3DP in CMF surgery, resulting in 63 articles being included. The main review findings were as follows: most used clinical applications were anatomical models and cutting guides; production took place in-house or as "in-house-outsourced" workflows; the surgeon alone was involved in POC 3DP in 36 papers; the use of free versus paid planning software was balanced (50.72% vs. 49.27%); average planning time was 4.44 h; overall operating time decreased and outcomes were favorable, though evidence-based studies were limited; and finally, the heterogenous cost reports made a comprehensive financial analysis difficult. Overall, the development of in-house 3D printed devices supports CMF surgery, and encouraging results indicate that the technology has matured considerably.

Early experience of wafer-free Le Fort I osteotomy with patient-specific implants in cleft lip and palate patients

The use of virtual surgical planning and patient-specific saw and drill guides combined with customized osteosynthesis is becoming a gold standard in orthognathic surgery. The aim of this study is to report preliminary results of the use of virtual surgical planning and the wafer-free PSI technique in cleft patients. Patient-specific saw and drill guides combined with milled patient-specific 3D titanium alloy implants were used in reposition and fixation in Le Fort I osteotomy of 12 cleft patients. Surgical information was retrieved from hospital records. Pre- and post-operative lateral cephalograms were analyzed. In 10 of 12 cases, the implants fitted as planned to predesigned drill holes and bone contours with high precision. In one patient, the mobilization of the maxilla was too demanding for virtually planned advancement, and the implants could not be used. In another patient, PSI fitting was impaired due to an insufficient mobilization of maxilla and tension on PSI fixation with screws. After the surgery, the mean advancement of the anterior maxilla (point A) of all patients was 5.8mm horizontally (range 2.7-10.1) and -3.1mm vertically (range -9.2 to 3.4). Skeletal relationships of the maxilla and mandible could be corrected successfully in all patients except for the one whose PSI could not be used. Virtual surgical planning combined with PSI is a possible useful clinical adjunct for the correction of maxillary hypoplasia in cleft patients. Large maxillary advancements and scarring may be cause problems for desired advancement and for the use of implants.

Reconstruction of an Atrophic Mandibular Fracture via a Customized, Intraoral Approach: A Novel Technique in the Treatment of Atrophic Mandibular Fractures

This study aims to describe the use of virtual surgical planning and a customized reconstruction plate with an inferior guide in the treatment of an atrophic mandibular body fracture via an intraoral approach. The literature reports the use of similar techniques in the reconstruction of atrophic mandibular fractures. However, to the knowledge of the authors, no studies report the application of this modality via an intraoral approach. A 77-year-old female who experienced a mechanical fall presented to the Oral and Maxillofacial Surgery Department at NYU Langone Health Hospital, New York, NY, in June 2021.

The Cost Utility of Virtual Surgical Planning and Computer-Assisted Design/Computer-Assisted Manufacturing in Mandible Reconstruction Using the Free Fibula Osteocutaneous Flap.

The use of virtual surgical planning and computer-assisted design and computer-assisted manufacturing (CAD/CAM) has become widespread for mandible reconstruction with the free fibula flap. However, the cost utility of this technology remains unknown. The authors used a decision tree model to evaluate the cost utility, from the perspective of a hospital or insurer, of mandible reconstruction using CAD/CAM relative to the conventional (non-CAD/CAM) technique for the free fibula flap. Health state probabilities were obtained from a published meta-analysis. Costs were estimated using 2018 Centers for Medicare and Medicaid Services data. Overall expected cost and quality-adjusted life-years (QALYs) were assessed using a Monte Carlo simulation and sensitivity analyses. Cost effectiveness was defined as an incremental cost utility ratio (ICUR) less than the empirically accepted willingness-to-pay value of $50,000 per QALY. Although CAD/CAM reconstruction had a higher expected cost compared with the conventional technique ($36,487 vs. $26,086), the expected QALYs were higher (17.25 vs. 16.93), resulting in an ICUR = $32,503/QALY; therefore, the use of CAD/CAM in free fibula flap mandible reconstruction was cost-effective relative to conventional technique. Monte Carlo sensitivity analysis confirmed CAD/CAM's superior cost utility, demonstrating that it was the preferred and more cost-effective option in the majority of simulations. Sensitivity analyses also illustrated that CAD/CAM remains cost effective at an amount less than $42,903 or flap loss rate less than 4.5%. This cost utility analysis suggests that mandible reconstruction with the free fibula osteocutaneous flap using CAD/CAM is more cost effective than the conventional technique.

Point of Care Virtual Surgical Planning and 3D Printing in Facial Feminization Surgery.

The use of virtual surgical planning (VSP) and three-dimensional printing (3DP) technologies in the routine facial feminization surgery practice has gained a significant popularity over the past few years. The clinical applications of them are claimed to improve safety, accuracy, and efficiency of facial feminization surgeries. In this article, we review and discuss the current applications of VSP and 3DP in different facial feminization procedures.

Virtual Planning and 3D Printing in Contemporary Orthognathic Surgery.

Orthognathic surgery is a powerful tool to improve facial balance, form, and function. Virtual planning and three-dimensional printing has improved our ability to visualize complex anatomy, consider various iterations and execute complex movements, and create accurate splints, plates, and cutting guides. This article will outline the distinct advantages of the use of virtual surgical planning over traditional planning, and it will explore the utility of computer-aided design and technology within contemporary orthognathic surgery, including its expanded applications and limitations.

Accuracy of virtual surgical planning and custom three-dimensionally printed osteotomy and reduction guides for acute uni- and biapical correction of antebrachial deformities in dogs.

To report clinical experience using virtual surgical planning (VSP) and surgical application of 3D printed custom surgical guides to facilitate uni- and biapical correction of antebrachial deformities in dogs. 11 dogs (13 antebrachial deformity corrections). Using CT-based bone models, VSP was performed, and surgical guides were designed and 3D printed. The guides were used to execute osteotomies and align bone segments. Postoperative CTs were obtained to compare limb alignment with the VSP. Long-term assessment of lameness and cosmesis were compared with preoperative status. Guides were successfully utilized and postoperative analysis was available for 10 of 13 deformities. Guides were abandoned in 2 deformities due to soft tissue tension. Evaluation of postoperative frontal, sagittal, axial, and translational limb alignment revealed that over 90% of parameters were within the acceptable range of ≤ 5° angulation and rotation or ≤ 5 mm of translation from the VSP. Lameness scores were improved in 7/8 deformities with associated preoperative lameness, and posture was improved in 10/10 deformities in which guides were deployed. Complications included reduced range of carpal motion (n = 2), implant sensitivity (n = 2), fracture (n = 1), and tendon laceration (n = 1). VSP and customized surgical guide application facilitated accurate antebrachial limb deformity correction in the majority of deformities in this case series. The use of VSP and 3D printed guides would appear to be a viable and accurate approach for correction of both uni- and biapical antebrachial deformities in dogs.