We aim to assess the value of patellofemoral
Aim of the study: To define the dimensions of the radial head, as well as the radiocapitellar and proximal radio-ulnar joints. The most congruent portions of the radial head articulations were determined. Materials &
Methods:
Purpose: We analysed outcome of 106 Latarjet-Patte procedures at 7.5 years mean follow-up.
Normal acetabular development in developmental dysplasia of the hip (DDH) depends upon early and maintained congruent reduction.
A primary goal of revision Total Knee Arthroplasty (rTKA) is restoration of the Joint Line (JL) and Posterior Condylar Offsets (PCO). The presence of a native contralateral joint allows JL and PCO to be inferred in a way that could account for patient-specific anatomical variations more accurately than current techniques. This study assesses bilateral distal femoral symmetry in the context of defining targets for restoration of JL and PCO in rTKA. 566 pre-operative CTs for bilateral TKAs were segmented and landmarked by two engineers. Landmarks were taken on both femurs at the medial and lateral epicondyles, distal and posterior condyles and hip and femoral centres. These landmarks were used to calculate the distal and posterior offsets on the medial and lateral sides (MDO, MPO, LDO, LPO respectively), the lateral distal femoral angle (LDFA), TEA to PCA angle (TEAtoPCA) and anatomic to mechanical axis angle (AAtoMA). Mean bilateral differences in these measures were calculated and cases were categorised according to the amount of asymmetry. The database analysed included 54.9% (311) females with a mean population age of 68.8 (±7.8) years. The mean bilateral difference for each measure was: LDFA 1.4° (±1.0), TEAtoPCA 1.3° (±0.9), AAtoMA 0.5° (±0.5), MDO 1.4mm (±1.1), MPO 1.0mm (±0.8). The categorisation of asymmetry for each measure was: LDFA had 39.9% of cases with <1° bilateral difference and 92.4% with <3° bilateral difference, TEAtoPCA had 45.8% <1° and 96.6% <3°, AAtoMA had 85.7% <1° and 99.8% <3°, MDO had 46.2% <1mm and 90.3% <3mm, MPO had 57.0% <1mm and 97.9% <3mm. This study presents evidence supporting bilateral distal femoral symmetry. Using the contralateral anatomy to obtain estimates for JL and PCO in rTKA may result in improvements in intraoperative accuracy compared to current techniques and a more patient specific solution to operative planning.
Analyzing shoulder kinematics is challenging as the shoulder is comprised of a complex group of multiple highly mobile joints. Unlike at the elbow or knee which has a primary flexion/extension axis, both primary shoulder joints (glenohumeral and scapulothoracic) have a large range of motion (ROM) in all three directions. As such, there are six degrees of freedom (DoF) in the shoulder joints (three translations and three rotations), and all these parameters need to be defined to fully describe shoulder motion. Despite the importance of glenohumeral and scapulothoracic coordination, it's the glenohumeral joint that is most studied in the shoulder. Additionally, the limited research on the scapulothoracic primarily focuses on planar motion such as abduction or flexion. However, more complex motions, such as internally rotating to the back, are rarely studied despite the importance for activities of daily living. A technique for analyzing shoulder kinematics which uses 4DCT has been developed and validated and will be used to conduct analysis. The objective of this study is to characterize glenohumeral and scapulothoracic motion during active internal rotation to the back, in a healthy young population, using a novel 4DCT approach. Eight male participants over 18 with a healthy shoulder ROM were recruited. For the dynamic scan, participants performed internal rotation to the back. For this motion, the hand starts on the abdomen and is moved around the torso up the back as far as possible, unconstrained to examine variability in motion pathway. Bone models were made from the dynamic scans and registered to neutral models, from a static scan, to calculate six DoF kinematics. The resultant kinematic pathways measured over the entire motion were used to calculate the ROM for each DoF. Results indicate that anterior tilting is the most important DoF of the scapula, the participants all followed similar paths with low variation. Conversely, it appears that protraction/retraction of the scapula is not as important for internally rotating to the back; not only was the ROM the lowest, but the pathways had the highest variation between participants. Regarding glenohumeral motion, internal rotation was by far the DoF with the highest ROM, but there was also high variation in the pathways. Summation of ROM values revealed an average glenohumeral to scapulothoracic ratio of 1.8:1, closely matching the common 2:1 ratio other studies have measured during abduction. Due to the unconstrained nature of the motion, the complex relationship between the glenohumeral and scapulothoracic joints leads to high variation in kinematic pathways. The shoulder has redundant degrees of freedom, the same end position can result from different joint angles and positions. Therefore, some individuals might rely more on scapular motion while others might utilize primarily humeral motion to achieve a specific movement. More analysis needs to be done to identify if any direct correlations can be drawn between scapulothoracic and glenohumeral DoF. Analyzing the kinematics of the glenohumeral and scapulothoracic joint throughout motion will further improve understanding of shoulder mechanics and future work plans to examine differences with age.
Summary Statement. It is now possible to diagnose osteoporosis using incidental abdominal CT scans; applying this approach to fractures of the cervical spine demonstrates levels of osteoporosis in patients over 65. Introduction. Recently published data now makes it possible to screen for osteoporosis in patients who, in the course of their hospital stay, have had
Our aim was to use CT Scanogram to evaluate fibular growth, and thus calculate normal growth velocity, which may aid in determining the timing of epiphysiodesis. Current understanding of normal lower limb growth and growth prediction originates in the work of Anderson et al published in the 1960s. There now exist several clinical and mathematical methods to aid in the treatment of leg length discrepancy, including the timing of epiphysiodesis. Early research in this area provided limited information on the growth of the fibula. It is now well recognized that abnormal growth of paired long bones may evolve into deformity of clinical significance. Existing work examining fibular growth used plain film radiography only.
Summary Statement. Using abdominal CT scans to evaluate bone mineral density following acute fractures of the thoracic and lumbar spine demonstrates significant levels of osteoporosis in older patients; this approach may help save on time and resources, and reduce unnecessary radiation exposure. Introduction. While a reduction in bone mineral density (BMD) is associated with aging, relatively few patients have formal dual-energy X-ray absorptiometry (DXA) to quantify the magnitude of bone loss, as they age. This loss of bone may predispose to fractures. Recent data, which correlates mean Hounsfield units (HU) in an area of the L1 vertebra with BMD, now makes it possible to screen for osteoporosis using incidental abdominal
In cases of severe postdysplastic coxarthosis, it seems to be impossible to recognize acetabular geometry and the real femoral position on a plain X-ray because the real diameters and angles can be disfigured when projected.
PURPOSE. Osteochondral talar defects (OCDs) are sometimes located so far posteriorly that they may not be accessible by anterior arthroscopy, even with the ankle joint in full plantar flexion, because the talar dome is covered by the tibial plafond. It was hypothesized that computed tomography (CT) of the ankle in full plantar flexion could be useful for preoperative planning. The dual purpose of this study was, firstly, to test whether CT of the ankle joint in full plantar flexion is a reliable tool for the preoperative planning of anterior ankle arthroscopy for OCDs, and, secondly, to determine the area of the talar dome that can be reached by anterior ankle arthroscopy. METHODS. In this prospective study, CT-scans with sagittal reconstructions were made of 46 consecutive patients with their affected ankle in full plantar flexion. In the first 20, the distance between the anterior border of the OCD and the anterior tibial plafond was measured both on the scans and during anterior ankle arthroscopy as the gold standard. Intra- and interobserver reliability of CT as well as agreement between CT and arthroscopy were assessed by intraclass correlation coefficients (ICCs) and a Bland and Altman graph. Next, the anterior and posterior borders of the talar dome as well as the anterior tibial plafond were marked on all 46 scans. Using a specially written computer routine, the anterior proportion of the talar dome not covered by the tibial plafond was calculated, both lateral and medial, indicating the accessible area. RESULTS. The distance between the anterior border of the OCD and the anterior tibial plafond ranged from −3.1 to 9.1 mm on CT and from −3.0 to 8.5 on arthroscopy. The intra- and interobserver reliability of the measurements made on CT-scans were excellent (ICC > 0.99, p < 0.001). Likewise, agreement between CT and arthroscopy was excellent (ICC=0.97; p < 0.001); only one patient showed a difference of more than 2.0 mm. The anterior 47.3 ± 6.8% (95%CI, 45.2–49.3) of the lateral talar dome, and 47.7 ± 7.0% (95%CI, 45.7–49.8) of the medial talar dome was not covered by the tibial plafond. CONCLUSIONS.
Introduction. A femoral rotational alignment is one of the essential factors, affecting the postoperative knee balance and patellofemoral tracking in total knee arthroplasty (TKA). To obtain an adequate alignment, the femoral component must be implanted parallel to the surgical epicondylar axis (SEA). We have developed “a superimposable
COVID-19 reduced availability of cross-sectional imaging, prompting the need to clinically justify pre-operative computed tomography (CT) in tibial plateau fractures (TPF). The study purpose was to establish to what extent does a CT alter the pre-operative plan in TPF compared to radiographs. There is a current paucity of evidence assessing its impact on surgical planning 50 consecutive TPF with preoperative CT were assessed by 4 consultant surgeons. Anonymised radiographs were assessed defining the column classification, planned setup, approach, and fixation technique. At a 1-month interval, randomised matched CT scans were assessed and the same data collected. A tibial plateau disruption score (TPDS) was derived for all 4 quadrants (no injury=0,split=1,split/depression=2 and depression=3). Radiograph and CT TPDS were assessed using an unpaired T-test.Abstract
INTRODUCTION
METHODOLOGY
Summary Statement. It is now possible to diagnose osteoporosis using incidental CT scans; this approach has been used to objectively demonstrate the role of osteoporosis in fracture in ankylosing spondylitis patients. Background. In advanced disease, Ankylosing Spondylitis (AS) is frequently associated with a reduction in bone mineral density (BMD), this contributes to pain and predisposes to fractures. Quantifying this reduction in BMD is complicated by the simultaneous processes occurring, in which there is both an overgrowth of bone (syndesmophytes) and a concurrent loss of trabecular bone. Traditional methods such as dual-energy X-ray absorptiometry (DXA) struggle to generate accurate estimates for BMD in these patients. It has recently become possible to diagnose osteoporosis, with a high sensitivity and specificity, using incidental CT scans of the L1 vertebra. The purpose of this study was to evaluate the use of opportunistic CT screening in the diagnosis of osteoporosis in patients with AS who had sustained vertebral fractures. Patients & Methods. Following Institutional review board approval, patients with AS who presented, with acute fractures of the spine, to our facility between 2004 and 2013 were reviewed to assess whether or not they had a
Anterior lumbar inter-body fusion (ALIF) is a surgical procedure that is available to chronic lower back pain patients who fail to respond to conservative treatments. Failure to achieve fusion may result in persistence of pain. Fusion of the lumber vertebral segment is more accurately assessed using fine-cut helical
Aim: To determine the quantity and the quality of the bone bridge between the bone tunnels, in both the femoral and tibial side, after double-bundle anterior cruciate ligament (ACL) reconstruction. Material and methods: Twenty-seven patients undergoing primary double-bundle ACL reconstruction with hamstring tendon autograft were included in this prospective study.
Introduction. Malrotation following total knee replacement is directly related to poor outcome. The knowledge of proximal and distal rotational axes and angles of the femur is therefore of high importance. The aim of the study was to determine whether the most used proximal and distal femoral angles; femoral anteversion angle (FAA) and posterior condylar angle (PCA) were different within individuals, between right, left and gender. As well, we studied whether the “inferior condylar angle” is correlated to the PCA and therefore useful in determining the rotation of the distal femur. Material and Methods. From 36 cadavers the femora were obtained and after removing the soft tissue a
Robotic-assisted technology in total knee arthroplasty (TKA) aims to increase implantation accuracy, with real-time data being used to estimate intraoperative component alignment. Postoperatively, Perth computed tomography (CT) protocol is a valid measurement technique in determining both femoral and tibial component alignments. The aim of this study was to evaluate the accuracy of intraoperative component alignment by robotic-assisted TKA through CT validation. A total of 33 patients underwent TKA using the MAKO robotic-assisted TKA system. Intraoperative measurements of both femoral and tibial component placements, as well as limb alignment as determined by the MAKO software were recorded. Independent postoperative Perth CT protocol was obtained (n.29) and compared with intraoperative values. Mean absolute difference between intraoperative and postoperative measurements for the femoral component were 1.17 degrees (1.10) in the coronal plane, 1.79 degrees (1.12) in the sagittal plane, and 1.90 degrees (1.88) in the transverse plane. Mean absolute difference between intraoperative and postoperative measurements for the tibial component were 1.03 degrees (0.76) in the coronal plane and 1.78 degrees (1.20) in the sagittal plane. Mean absolute difference of limb alignment was 1.29 degrees (1.25), with 93.10% of measurements within 3 degrees of postoperative CT measurements. Overall, intraoperatively measured component alignment as estimated by the MAKO robotic-assisted TKA system is comparable to CT-based measurements.
In total knee arthroplasty, polyethylene wear has been a major cause of revision surgery. However, it is sometimes difficult to determine the time of revision surgery in elderly people due to their concomitant diseases. Therefore, the brace for measuring polyethylene wear under computed tomography was developed. The brace works by strapping a femoral component tightly to a polyethylene insert by applying compression force between the sole of the foot and the thigh. Holes of 1, 2, 5, 10 mm in diameter and 0.1, 0.2, 0.5 and 1 mm in depth were created in the posteromedial part of polyethylene inserts. The inserts were provided from Teijin-nakashima Co. ltd. (Jodo, Okayama, Japan). The Hi-tech knee artificial joint (Teijin-nakashima Co. ltd.) was applied to a cadaveric knee and CT images of the knee were taken with a combination of insets with varying diameters and depths holes, using Aquilion ONE (Toshiba Medical Systems Corporation, Ohtawara, Japan). The finding conditions were as follows, Voltage; 120V, Current; 5A, slice thickness; 0.5 mm helical. The patient, who received total knee arthroplasty over 15 years ago, wore the brace and was examined using computed tomography. Afterward, the patient received revision surgery to replace the worn insert into new one. The removed insert was measured with a three-dimensional measuring machine (Cyclon, Mitsutoyo Co. ltd., Kawasaki, Japan). At a 1.0 mm depth, all holes could be detected. At a 0.5 mm depth, holes of 2, 5, 10 mm in diameter could be detected. At a 0.1∼0.2 mm depth, there was no hole detected. After revision surgery, a three-dimensional measuring machine revealed a 1.8 mm thickness of the insert on the medial side. The CT reconstruction image showed a1.84 mm thickness similar to the virtually measured figure.Methods
Results
Surgical navigation requires an accurate, stable transformation between the tracking system and reference images. This study was the design and evaluation of an additively manufactured calibrator with an integrated verification tool, used to register cone-beam computed tomography (CBCT) image volume to electromagnetic (EM) tracking. An Aurora EM system was used to track both the calibrator and a surgical probe. Intraoperative CBCT images were acquired with a GE Innova 4100 scanner. The calibrator incorporated 7 tantalum beads, a 6DOF EM sensor, and 7 through-holes for calibrator verification. The calibrator was characterised using the beads and averaged EM reading in 10 poses. Target Registration Error (TRE) estimation used a device with 14 beads and 18 through-holes. For verification, the probe was placed in each path and the axis and tip location measured relative to the calibrator. This verification task took about 45s. Axial error was the angle between the probed paths and designed axes; translation error was the shortest distance between these lines. The translation TRE was 3.14±0.96 mm and the angular TRE was 1.7±0.7 degrees, which is consistent with published EM evaluations. The validation axes had an inter-line distance of 0.9±0.78 mm and an axial difference of 1.1±0.7 degrees. The verification errors were smaller than TRE because of the different mathematical formulation. Although the verification calculation was not exactly a tracking error, it provided an alternative quantitative assessment of registration accuracy. This integrated intra-operative registration verification minimises modifications to the surgical workflow and these results demonstrated highly accurate orientation tracking in a surgical environment.
To asses the accuracy of total knee replacements performed using CT based patient specific instrumentation by postoperative CT scan. Approval from the Ethics Committee at The University of New South Wales Sydney Australia was granted prior to commencement of this study. 50 patients who had undergone total knee replacement (Evolis, Medacta International) using CT-based patient specific instrumentation (MY KNEE Medacta International) were assessed postoperatively using a CT scan and a validated measurement technique. The mechanical axis of the limb in the coronal plane, the varus/valgus positioning of the femoral component, the varus/valgus positioning of the tibial component, the flexion/extension of the posterior flange of the femoral component and the posterior slope of the tibial base plate were recorded. These results were then compared to each patient's preoperative planning. The percentage of patients found to be within 3 degrees of planned alignment were calculated. This represents the most comprehensive prospective study to utilize CT assessment of postoperative alignment in patient specific instrumentation. All other studies, to our knowledge have utilized scanograms or scout images and not full CT protocol as performed in this study.Aim
Method
The number of complex revision total hip arthroplasties (THA) is predicted to rise. The identification of acetabular bone defects prior to revision THA has important implications on technique and complexity of acetabular reconstruction. Paprosky et al. proposed a classification system including 3 main types with up to 3 subtypes focused on the integrity of the superior rim of the acetabulum and medial wall. However, the classification system is complex and its reliability has been questioned. The purpose of this study was to evaluate the effectiveness of different radiologic imaging modalities (plain radiographs, 2-D CT, 3-D CT reconstructions) in classifying acetabular defects in revision hip arthroplasty cases and their value of at different levels of orthopaedic training. Patients treated with revision total hip arthroplasty for acetabular bone defects between 2002–2012 were identified and 22 cases selected that had plain radiographs, 2-D CT and 3-D reconstructions available. Bone defects were classified independently by two fellowship-trained adult reconstruction surgeons. Representative sections were chosen and compiled into a timed presentation. Thirty-five residents from PGY-1 to PGY-5 and 4 attending orthopaedic surgeons were recruited for this study and received a 15-minute introduction to the classification system. Chi square analysis was utilized to examine the influence of image modality and level of training on the correct classification of acetabular bone loss using the Paprosky classification system with alpha=0.05.Introduction
Methods
Histology remains the gold standard in morphometric and pathological analyses of osteochondral tissues in human and experimental bone and joint disease. However, histological tissue processing is laborious, destructive and only provides a two-dimensional image in a single anatomical plane. Micro computed tomography (μCT) enables non-destructive three-dimensional visualization and morphometry of mineralized tissues and, with the aid of contrast agents, soft tissues. In this study, we evaluated phosphotungstic acid-enhanced (PTA) μCT to visualize joint pathology in spine osteoarthritis. Lumbar facet joint specimens were acquired from six patients (5 female, age range 31–78) undergoing decompression surgery. Fresh osteochondral specimens were immediately fixed in formalin and scanned in a benchtop μCT scanner (65 kV, 153 mA, 25 μm resolution). Subsequently, samples were completely decalcified in 5% formic acid, equilibrated in 70% ethanol and stained up to ten days in 1% PTA (w/v) in 70% ethanol. PTA-stained specimens were scanned at 70 kV, 140 mA, 15 μm resolution. Depth-dependent analysis of X-ray attenuation in cartilage tissues was performed using ImageJ. Bone structural parameters of undecalcified and PTA-stained specimens were determined using CT Analyser and methods were compared using correlation and Bland-Altman analysis.Introduction
Methods
Osteophytes are bony spurs on normal bone that develop as an adaptive reparative process due to excessive stress at/near a joint. As osteophytes develop from normal bone, they are not always well depicted in common imaging techniques (e.g. CT, MRI). This creates a challenge for preoperative planning and image-guided surgical methods that are commonly incorporated in the clinical routine of orthopaedic surgery. The study examined the accuracy of osteophyte detection in clinical CT and MRI scans of varying types of joints. The investigation was performed on fresh-frozen ex-vivo human resected joints identified as having a high potential for presentation of osteophytes. The specimens underwent varying imaging protocols for CT scanning and clinical protocols for MRI. After dissection of the joint, the specimens were subjected to structured 3D light scanning to establish a reference model of the anatomy. Scans from the imaging protocols were segmented and their 3D models were co-registered to the light scanner models. The quality of the osteophyte images were evaluated by determining the Root Mean Square (RMS) error between the segmented osteophyte models and the light scan model. The mean RMS errors for CT and MRI scanning were 1.169mm and 1.419mm, respectively. Comparing the different CT parameters, significance was achieved with scanning at 120kVp and 1.25mm slice thickness to depict osteophytes; significance was also apparent at a lower voltage (100kVp). Preliminary results demonstrate that osteophyte detection may be dependent on the degree of calcification of the osteophyte. They also illustrate that while some imaging parameters were more favourable than others, a more accurate osteophyte depiction may result from the combination of both MRI and CT scanning.
We graded the contralateral hip for severity of joint space narrowing on plain radiographs.
In total hip arthroplasty (THA), the femoral component influences leg length inequality and gait, and is associated with poor muscle strength and other unsatisfactory long-term results. We have therefore used intraoperative radiographs to acquire accurate measurements of femoral component size and position. At the last meeting of this society, we reported that accurate positioning was successfully achieved in 68 cases (87.2%) as a consequence of taking intraoperative radiographs. However, we have little understanding as regards to the accuracy of X-ray measurements. We accordingly undertook an examination of the accuracy of such measurements. The purpose of this study was to evaluate the difference between leg length discrepancy (LLD) measured using X-ray and computed tomography (CT). The study group comprised 48 primary THAs performed between October 2010 and April 2012. Using 2D template software (JMM Corporation), we measured LLD using pre-operative anteroposterior (AP) radiographs of the pelvis. On the basis of both teardrop lines, we measured LLD of the lesser trochanter top (Fig. 1), lesser trochanter direct top (Fig. 2), and trochanteric top (Fig. 3). Furthermore, using Aquarius NET software, we measured LLD using AP and lateral scout views of the pelvis and bilateral femurs. This data was defined as the true LLD. The difference between the X-ray data (lesser trochanter top, lesser trochanter direct top, and trochanteric top) and the CT data was defined as accuracy. Additionally, we measured the size of the lesser trochanter and examined the association.Objective
Materials and Methods
The authors are not aware of any research comparing computed tomography (CT) and avascular necrosis (AVN) of the scaphoid bone. The primary aim of our study was to investigate the use of longitudinal CT in predicting AVN of the proximal pole of the scaphoid, and subsequent fracture nonunion following internal fixation. Thirty-two patients operated on by the senior author for scaphoid fracture were included. Preoperative CT scans were independently assessed for deformity, comminution, fracture position, proximal pole sclerosis, and bridging trabeculae. Intra-operative biopsy of the proximal pole was assessed independently by a blinded musculoskeletal histologist. AVN was determined by histology of a proximal pole biopsy, using the criteria described by Ficat. Post-operative CT scan was utilised to determine fracture union. Preoperative CT features which significantly correlated with AVN were, increased radiodensity of the proximal pole, the absence of any bridging trabeculae comminution, dorsal cortical angle, proximal fracture and age less than 20. Features predictive of subsequent nonunion were fractures of the proximal, increased radiodensity of the proximal pole, and AVN. Preoperative CT scan findings are significantly correlated with histologically confirmed AVN and fracture union. Preoperative longitudinal CT scan is of significant prognostic value and should be considered to assist in predicting outcome and assessing treatment options.
[Hong Kong Orthopaedic Association, Travelling Fellow] Glenoid bone loss predisposes to further dislocation and failure of arthroscopic Bankart repair in patients with recurrent shoulder dislocation. This study investigates quantification of glenoid bone loss in anterior shoulder dislocation using computerized tomography (CT). CT was performed in 40 patients (average age 31 years, range 16–82 years) with anterior shoulder dislocation. Of this group, 42 shoulders with anterior dislocation and 38 contralateral normal shoulders were examined. In addition, twenty shoulders in ten normal subjects were examined. CT technique comprised 1mm acquisition, pitch 1.0, simultaneously of both shoulders. Reformatted images en face to the glenoid fossa were obtained. Ten different measures of the glenoid fossa were obtained including cross sectional area, maximum height, and width and flattening of the anterior curvature of the glenoid. In normal subjects, maximum side to side difference in cross-sectional area was 14% and maximum glenoid width 4.1mm. For dislocating shoulders, flattening of the anterior edge of the glenoid fossa and a reduction in maximum glenoid width were the best objective criteria of bone loss. Flattening of the anterior glenoid curvature was a feature of 95% dislocated shoulders though was only seen in 1.5% of normal shoulders. Glenoid cross-sectional area was not a useful measure of glenoid bone deficiency. Variable glenoid bone loss is a measurable feature of anterior shoulder dislocation. CT can be used to objectively assess this preoperatively. This should help when deciding on whether to perform an arthroscopic Bankart repair or open bone block procedure.
Humeral retroversion is variable among individuals, and there are several measurement methods. This study was conducted to compare the concordance and reliability between the standard method and 5 other measurement methods on Twodimensional (2D) computed tomography (CT) scans. CT scans from 21 patients who underwent shoulder arthroplasty (19 women and 2 men; mean age, 70.1 years [range, 42 to 81 years]) were analyzed. The elbow transepicondylar axis was used as a distal reference. Proximal reference points included the central humeral head axis (standard method), the axis of the humeral center to 9 mm posterior to the posterior margin of the bicipital groove (method 1), the central axis of the bicipital groove –30° (method 2), the base axis of the triangular shaped metaphysis +2.5° (method 3), the distal humeral head central axis +2.4° (method 4), and contralateral humeral head retroversion (method 5). Measurements were conducted independently by two orthopedic surgeons.Background
Methods
Fixation patterns of cementless stem were known as proximal or distal part. Distal fixation was seen in fully porous coated stem and stress shielding of the proximal femur was indicative. These phenomena did not lower the clinical results, but technical difficulties were more and more in revision surgery because of infection or dislocation. There was lot of reports that alendronate was effective for treatment of osteoporosis by induction of apoptosis in osteoclasts. We can expect alendronate to modify the bone quality around the stem after cementless THA. We studied prospectively that quantitative computed tomography (QCT) measured bone mineral density around the stem between alendronate group and control. We tried to clarify that stress shielding after cementless THA can be prevented by use of alendronate or not.Introduction
Objectives
The treatment of trochanteric femoral fractures with the use of short femoral nails has become an established method. The fixation is required that lag screw be centered to prevent complications. But correct positioning of the device may difficult because of anatomical feature. This study evaluated the femoral morphology three-dimensionally using computed tomography (CT) images. Seventy eight patients (mean age 75)who underwent total knee arthroplasty were included. After three-dimensional reconstruction of the CT images, the anterior deviation from the femoral neck axis to proximal shaft axis was measured. The proximal shaft axis was defined as a line between center of the cross-section underneath the lesser trochanter and the center of diaphysis. The connection of center in narrow section of the neck and femoral head center was defined as neck axis.Introduction
Methods
The orientation of the acetabular component in metal-on-metal hip resurfacing arthroplasty affects wear rate and hence failure. Correct assessment of acetabular orientation is key in assessing the painful hip resurfacing. This study aimed to establish if interpretation of pelvic radiographs with TraumaCad software can provide a reliable alternative to computed tomography (CT) in measuring the acetabular inclination and version. TraumaCad was used to measure the acetabular orientation on AP pelvis radiographs of 14 painful hip resurfacings. Four orthopaedic surgeons performed each measurement twice. These were compared with measurements taken from CT reformats performed by an experienced musculoskeletal radiologist. The correlation between TraumaCad and CT was calculated, as was the intra- and inter-observer reliability of TraumaCad. There is strong correlation between the two techniques for the measurement of inclination and version (p<0.001). Intra- and inter-observer reliability of TraumaCad measurements are good (p<0.001). Mean absolute error for measurement of inclination was 2.1°. TraumaCad underestimated version compared to CT in 93% of cases, by 12.6 degrees on average. When assessing acetabular orientation in hip resurfacing, the orthopaedic surgeon may use TraumaCad in the knowledge that it correlates well with CT and has good intra- and inter-observer reliability but underestimates version by 12° on average. This underestimation may be contributed to by the natural divergence of the X-ray beam, the short arc of the ellipse left exposed by the large diameter head, and the non-hemispherical resurfacing cup.
Positioning the inferior screw fully inside the lateral border of the scapula correlates with lower bony coverture of superior screw.
The purpose of this study was to evaluate in vivo fit and fill analysis of tapered wedge-type stem in total hip arthroplasty (THA) with computed tomography (CT)-based navigation system. 100 THAs were all performed through the posterolateral approach, with patients in the lateral decubitus position. Each cohort of 50 consecutive primary cementless THAs with was compared with and without CT-based navigation system. The post-operative antero-posterior (AP) hip radiographs were obtained two weeks after the operation. All radiographic fit and fill measurements in the proximal and distal areas were analyzed by two of the authors who were both blinded to the use of CT-based navigation system. The type of the fit in the cementless stem was divided into three types. The fit of the stem was classified as Type I, if there was both proximal and distal engagement (maximum proximal to distal engagement difference of 2 mm or greater), Type II when there was proximal engagement only, and Type III when there was distal engagement only. The fill parameters such as mean stem-to-canal ratios and mean minimum and maximum gaps between the stems to the cortical bone in proximal and distal sections were compared. There was a significantly better overall canal fit obtained by THA with CT-based navigation system compared to without the navigation system (p<0.01). With CT-based navigation system, 42 of 50 stems (84%) were categorized as Type I fit compared to 31 of 50 stems (62%) without the navigation system. As to Type II fit, There are significantly more stems without the navigation system (26%) compared to with it (12%). There were better canal fills of the stems obtained by THA with CT-based navigation system both in proximal (94%) and distal sections (88%) of the femur compared to without the navigation system (proximal 88%/distal 82%) (p<0.05). Excellent radiographic fit and fill has been previously reported to potentially correlate with improved clinical outcomes. The stems obtained by THA with CT-based navigation system had a significantly better canal fit demonstrated by higher proportion of Type I and lower proportion of Type II fits, compared to without the navigation system. The stems with the navigation system had also significantly better proximal and distal canal fill.
The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up.Aims
Methods
Articular cartilage has a limited regeneration capacity, and damage of cartilage often results in the onset of degenerative disease such as osteoarthritis (OA). MRI and CT imaging of cartilage and subchondral bone are becoming increasingly important in early detection and treatment of OA as well as for quantifying quality of tissue-engineered samples. Non-invasive CT scanners have been used to image cartilage tissue with the help of contrast agents. However, since only one energy source is available, imaging information of multiple soft and hard tissues is lost given that the overall x-ray attenuation is measured. Medipix All Resolution System (MARS) CT offers the possibility of applying more than one energy source. It is able to measure the energy of each photon individually and therefore determines the characteristics of attenuation. In this study, an ionic contrast agent (Hexabrix) was used to image the negatively charged extra-cellular matrix component, glycosaminoglycan (GAG), which is abundantly found in the middle and lower layers of healthy cartilage tissue. GAG distribution in the cartilage tissue could be imaged using an inverse relationship with Hexabrix signal (i.e. high signal represents low GAG content). Eight bovine cartilage-bone explants (3mm × 5mm) were incubated in 4 different Hexabrix concentrations ranging from 20% to 50% in PBS. Sections were imaged using the MARS scanner at high and low energies (13.32 keV and 30.84 keV). Images were pre-processed, reconstructed and colour-coded using different enhancement techniques and virtual experimental software. Histological (Safranin-O) staining and quantitative biochemical analysis of GAG content (DMMB dye assay) was performed to correlate GAG distribution and content with MARS-CT images. High resolution images of both cartilage and bone regions were obtained, with contrast enhanced CT of cartilage correlating well with histological staining. X-ray attenuation was high in regions poor in GAG content, whereas attenuation was low in GAG rich regions. Furthermore, there was a direct inverse correlation between Hexabrix signal and GAG content as measured in superficial (2.9 μg/mg) and middle/deep regions (10.6 μg/mg) in cartilage explants. It can be concluded that the MARS technique can be used to image GAG distribution and GAG content, and therefore could be used clinically to assess quality of healthy or osteoarthritic cartilage, as well as non-destructive imaging of GAG content in engineered tissues.
posteromedial shear fracture; coronal plane fracture; lateral condylar impaction; medial condylar impaction; tibial spine involvement; separation of tibial tubercle necessitating anteroposterior lag screw fixation. In addition, fractures were classified according to the AO/OTA Comprehensive Classification of Fractures, the Schatzker classification system and the Hohl and Moore system. Two rounds of evaluation were performed and then compared. First, a combination of plain radiographs and two-dimensional computed tomography scans (2D) were evaluated, and then, four weeks later, a combination of radiographs, two-dimensional computed tomography scans, and three-dimensional reconstructions of computed tomography scans (3D) were assessed.
Three-dimensional computed tomography reconstructions also improved the average intraobserver reliability for all fracture characteristics, from κ2D = 0.624 (substantial agreement) to κ3D = 0.687 (substantial agreement). The addition of three-dimensional images had limited infiuence on the average interobserver reliability for the recognition of specific fracture characteristics (κ2D = 0.488 versus κ3D = 0.485, both moderate agreement). Three-dimensional computed tomography images improved interobserver reliability for the recognition of coronal plane fractures from fair (κ2D = 0.398) to moderate (κ3D = 0.418) but this difference was not statistically significant.
individual orthopaedic surgeons for preoperative planning (improves intraobserver reliability for the recognition of fracture characteristics), and for comparison of clinical outcomes in the orthopaedic literature (improves interobserver reliability of classification systems).
Apert’s syndrome (or acrocephalosyndactyly type 1) is a rare condition characterized by anomalies of the skull (craniosynostosis) in conjunction with complex syndactyly of the hands and feet. There are many studies involving the description and management of hand deformities in Apert’s syndrome. The study of foot anomalies however in children with Apert’s syndrome has been limited to individual case reports and small series. Plain radiographic studies have shown that during childhood, progressive fusion of the bones of the feet occurs. The management of these children’s feet has never been addressed in the literature. Seven patients with Apert’s syndrome were included in our study. The study group consisted of 2 girls and 5 boys, age range 4–16 years. We performed plain radiography, 3-D computed tomography and paedobarographic studies on all seven children based on our observation that some children with Apert’s had prominent metatarsal heads with symptomatic callosities under the first and second metatarsal heads. Five of the seven children studied demonstrated a specific pattern both on paedobarographic studies and 3D computed tomography of an excessively plantar flexed, fused first and second rays. A corrective extension osteotomy of the fused first and second rays were then carried out in one patient with an excellent post-operative result. We propose that by early recognition and correction of the pattern of an excessively plantar flexed first and second ray would improve both function and footwear.
To evaluate whether an ultra-low-dose CT protocol can diagnose
selected limb fractures as well as conventional CT (C-CT). We prospectively studied 40 consecutive patients with a limb
fracture in whom a CT scan was indicated. These were scanned using
an ultra-low-dose CT Reduced Effective Dose Using Computed Tomography
In Orthopaedic Injury (REDUCTION) protocol. Studies from 16 selected
cases were compared with 16 C-CT scans matched for age, gender and
type of fracture. Studies were assessed for diagnosis and image
quality. Descriptive and reliability statistics were calculated.
The total effective radiation dose for each scanned site was compared.Aims
Patients and Methods
Periprosthetic osteolysis is a serious medium to long-term complication of total hip arthroplasty. Interobserver reliability of detecting osteolysis around cementless ace-tabular components is reported to be poor using plain radiographs. Quantitative computed tomography (CT) provides sensitive and accurate measures of osteolytic lesion volume, however, there may remain a role for plain radiographs in monitoring progression of osteolysis. The aim of this study was to use quantitative CT to monitor the progression of osteolytic lesions around cementless acetabular components and to compare plain radiographs and CT in determining the progression of osteolysis. A high-resolution multi-slice quantitative CT scanner with metal artefact suppression was used to determine the volume of osteolysis around 18 cementless acetabular components. The mean time since arthroplasty was 14 years (range 10–15 years) at the initial CT. Repeat scans of the hip were undertaken over a five-year period to determine progression of osteolysis with time. A second blinded observer examined anteroposterior and lateral plain radiographs taken at the same time as the CT scans and measured the location and area of osteolytic lesions. CT measurements determined that in ten of 18 hips (56%), osteolytic lesions progressed by more than 1cm3/yr. Progression in size of osteolytic lesions was significantly associated with hips with larger osteolytic lesions at the initial CT (p=0.0005). The mean volume of osteolysis progression was 4.9cm3/year (range 2.8–7.5cm3/yr) for cases with osteolysis volumes greater than 10cm3 at the initial CT, and 0.7cm3/yr (range 0–2.3cm3/yr) for cases with osteolysis volumes smaller than or equal to 10cm3 at the initial CT (p=0.002). Importantly, the rate of osteolysis progression between CT scans varied greatly in some hips. In contrast, using plain radiograph assessment, progression in the area of osteolytic lesions was only detected in 10% of hips. In conclusion, quantitative CT provides new insights into the natural history of periacetabular osteolysis. Total osteolysis volume greater than 10cm3 is associated with a high risk of progression and progress, on average, at a greater rate than those less than 10cm3. Plain radiographs, including a lateral view, are an unreliable clinical diagnostic tool to predict substantial progression of periacetabular osteolytic lesions.
We usually plan surgery for total hip arthroplasty (THA)using pre-operative X-ray templates. However, the technique provides only two dimensional (2D) images and therefore has limitations for planning three-dimensional (3D) objects. Recently it has become possible to describe 3D images using computer programs that use free down loaded computer software (Hip-op) that enable comparison between 3D templates obtained by computed tomography (CT) and 2D conventional X-ray templates. Six hip joints in 6 patients (1 male, 5 females; age range at the time of operation, 49–77 years) were evaluated. Five of the patients suffered from secondary osteoarthritis of the hip (secondary OA), while the remaining patient suffered from osteonecrosis of the femoral head (ONFH). All the patients underwent THA using a cement less femoral stem (ANCA-FIT Wright Medical Technology, Arlington, Tennessee, USA). Pre-operative planning was performed using Hip-op software (Rizzoli Institute, Bologna, Italy). After the THA surgery, we carried out a repeat CT scan that was used to analyze stem fitting in the femur. In all the patients it proved easy to obtain the pre-operative template. In 4 patients, the correct stem size was selected pre-operatively, while in the other 2 patients, the planned stem size was one size smaller than that actually implanted. In the 4 patients in whom the correct stem was selected, 2 had their template correctly assessed by conventional 2D images, 1 patient’s template was one size smaller than the implant, while the remaining patient’s template was two sizes smaller than the implant. In the 2 patients who received implants one size smaller than the CT template, 1 patient had the stem inserted in the virus position while in the other patient a fracture occurred during implantation Preoperative planning for THA using a CT-based computer templating system proved to be a useful technique for the orthopedic surgeons.
Seven knees from seven donors (2M:5F; age:46+/−11) were scanned three times via QCT (GE Lightspeed; BMD Phantom; 0.625x0.625x0.625mm resolution). CTTOMASD regional analyses were performed for medial and lateral compartments; outputting density versus depth plots fit with polynomial regression equations. As density decreases with increased depth from the subchondral surface, a density threshold of 300mg/ cm3 was arbitrarily set to correspond with the safe resurfacing depth. The 300mg/cm3 density threshold corresponds to the average density of subchondral trabecular bone, and is ~2x the density of weak epiphyseal trabecular bone located beneath stiffer subchondral trabecular bone. Precision was defined using coefficients of variation (CV%). In-vivo precision errors associated with CT-TOMASD safe resurfacing depths were less than 2.7%. CV% was 2.7% for the medial compartment depth and 2.6% for the lateral compartment depth. CT-TOMASD demonstrates repeatable measures of safe resurfacing depths invivo. Safe resurfacing depths are measured in relation to defined density thresholds which can be adjusted according to UKA design and patient specifics (e.g., size, sex). CT induces a low radiation dosage due to the low presence of radiosensitive tissues at the knee (~1/10th of a long-leg standing radiograph). CT-TOMASD has potential to be used as a pre-operative imaging technique for improved UKA stability and longevity.
We evaluated the geometry of the resected femoral surface according to the theory for total knee arthroplasty (TKA) using three-dimensional computed tomography (3D CT). The 3D CT scans were performed in 44 knees indicated as requiring total knee arthroplasty. The 3D images of the femurs were clipped according to the following procedures. The distal femur was cut perpendicular to the mechanical axis at 10 mm proximal from the medial condyle. Rotational alignment was fixed at 3 degrees external rotation from the posterior condylar line. The anterior condyle was resected using the anterior cortex as the reference point. The posterior condyle was cut at 10 mm anterior from the medial posterior condyle. The medial-lateral (ML) width/anterior-posterior (AP) length was 1.58 ± 0.14 (mean ± SD). AP length of the 3D images tended to be longer than the box length of the three kinds of components provided when the ML width of the images was approximately equal to that of each component. The widths of medial and lateral posterior condyles of the images were 30.1 ± 3.8 mm and 24.8 ± 3.0 mm, respectively. In all except one case, the widths of the resected medial posterior condyles were greater than those of the medial condyles of all components when those of resected lateral posterior condyles were equal to those of the lateral condyles of the components. The shapes of the resected femoral surface did not always match those of the components. The configuration of Japanese knee joints is different from that of American knee joints. Components with appropriate geometry should be designed for Japanese patients.
The scapulo-humerothoracic rhythm, which can be described by up to 12 spatial variables, is either responsible for, or affected by the genesis of shoulder pathology and trauma, and therefore, imaging the articulations of the shoulder through a global range of motion is desirable in aiding the diagnosis and management of both movement deficiency and osseous lesions. 4 control volunteers were seated between the toroid of the scanner and maximally slewn table on a customised tripod. The subjects were asked to carryout a sequence of defined movements, each over a period of 5 seconds. These included adduction to abduction in the scapular plane, internal rotation to external rotation at 0° and 90° abduction and flexion to extension. An EBCT C300 scanner was used with a multislice sequence imaging protocol to collect 8 transaxial slices per volume by sweeping an x-ray beam sequentially over 4 tungsten target rings and recording x-ray intensity via two fixed detector rings after the reflected beam passes through the body, enabling the acquisition of 20 volumes per movement with minimal radiation exposure. Each slice was post-processed by semi-automatic segmentation using Amira software, and reconstructed to produce three-dimensional reconstructions. Following this, a kinematic description of the joint complex was developed using SIMM, enabling quantification of up to 5 Degrees of Freedom at the Glenohumeral joint. EBCT provides a quick and efficient method for direct real-time dynamic imaging of the shoulder girdle, although currently crude. As such, we hypothesis the ability of EBCT to image traumatic disruption to shoulder rhythm, and are currently pursuing this work. These reconstructions promise great potential for further clinical experience and quantitative analysis of small translations aided by achievable limited technological refinement of the modality.
Since acetabular osteolytic lesions following total hip arthroplasty (THA) may be asymptomatic until extensive bone loss occurs, early detection and monitoring the progression of these lesions is important. The purpose of this study was to use high resolution helical CT to determine the progression of the osteolytic lesions over time by comparing serial studies. Fifty patients (Fifty-eight hips) with primary, cementless THA done between 1984–1996 were evaluated as part of an ongoing prospective study. These patients had a history of a high level of activity that was believed to place them at increased risk for accelerated polyethylene wear. The mean age was 51 yrs, 55% male:45% female. The average time from date of surgery to initial scan was 8.0 years (4.7–16.6). If an acetabular lytic lesion was identified, the patients were offered Alendronate for potential suppression of bone resorption with a repeat CT scan for follow-up. The area of the maximum size osteolytic lesions on axial images were measured on the initial scan and compared at the same level on the subsequent study. The interval between scans averaged 15 months (10 – 27). Progression was noted on 87% hips. The mean initial area was 328 mm2 (40–1084) with the follow-up area of 386 mm2 (46–1344) with a mean of progression of 15.7%. Once established, peri-acetabular lysis appears to be a slowly progressive, relentless process. Analysis of changes on serial CT, along with an assessment of the degree and location of lysis, provides an additional tool to evaluate the need for surgical intervention.
The purpose of this study was to investigate the bone anatomy in determining the rotational alignment in total knee arthroplasty (TKA) using CT scan. Axial CT images of eighty-four varus osteoarthritic knees undergoing TKA were analysed. On the images of the distal femur and the proximal tibia, base line for anterior-posterior axis of each component was drawn based on the epicondylar axis for the femur and medial one-third of the tibial tuberosity for the tibia. Angle between these two lines was analysed as the rotational mismatch between the components when they were determined based on the anatomical landmark of each bone. Thirty-eight knees (45%) showed more than 5-degree mismatch and seven knees (8.3%) showed the mismatch more than 10-degree. There was a tendency to put the tibial component in external rotation relative to the femoral component when they were aligned to medial one-third of the tibial tuberosity. The results have indicated that the landmark of each bone was the intrinsic cause of the rotational mismatch between the components. The surgeons performing TKA surgery should aware of this fact and should align the tibial component in a compromised position, if necessary, to have overall satisfactory clinical outcome.
Previous studies have suggested that bone ongrowth occurs following revision hip arthroplasty to a tapered long stem distal fit modular prosthesis. This may affect outcome. We sought to quantify proximal bone ongrowth to one such prosthesis and correlate this with functional outcome. A series of eight patients undergoing revision total hip arthroplasty with the a long taper, distal fit, grit blasted modular prosthesis (ZMR) had a CT performed within three months and then greater than one year following surgery. Changes in periprosthetic bone stock were measured. Functional scores at a minimum of five years were analysed. Proximal bone ongrowth was generally poor and did not correlate with functional outcome score. When more sensitive imaging is used to analyse bone ongrowth in this long stem distal fit prosthesis, proximal ongrowth is poor and not the key determinate of functional outcome. In relation to the conduct of this study, no funding has been received from any source to support the costs of this study
In this randomized study, we aimed to compare quality of regenerate in monolateral Both groups were comparable in demographic and injury characteristics. A phantom (aluminium step wedge of increasing thickness) was designed to compare the density of regenerate on radiographs. A CT scan was performed at three and six months postoperatively to assess regenerate density. A total of 30 patients (29 male, one female; mean age 32.54 years (18 to 60)) with an infected nonunion of a tibial fracture presenting to our tertiary institute between June 2011 and April 2016 were included in the study.Aims
Patients and Methods
One of the complications occurring after total knee arthroplasty (TKA) is venous thromboembolism (VTE). The current screening techniques for VTE are venography, lower extremity vascular ultrasound, pulmonary scintigraphy, and contrast-enhanced computed tomography (CT). Although venography and lower extremity vascular ultrasound can detect deep venous thrombosis (DVT) in the lower extremities, pulmonary thrombosis poses a diagnostic problem. We performed contrast-enhanced CT screening for DVT and pulmonary embolism (PE) after TKA, and assessed the efficacy of the following prophylactics for VTE: fondaparinux, enoxaparin, and edoxaban. Subjects included 219 patients (260 knees) undergoing TKA at our hospital between April 2007 and November 2012. The 260 subject knees were divided as follows: group C, 31 cases in which DVT prophylactics were not used (April 2007 to October 2008); group F, 107 cases receiving fondaparinux 2.5 mg/day (July 2007 to October 2009); group ENO, 87 cases receiving enoxaparin 2000–4000 IU/day (November 2009 to October 2011); and group EDO, 35 cases receiving edoxaban 15–30 mg/day (November 2011 to November 2012). Contrast-enhanced CT images were obtained from the pulmonary apex to the foot for diagnosis of VTE. Groups were compared for incidence of symptomatic PE, asymptomatic PE, DVT-negative asymptomatic PE, DVT-positive asymptomatic PE, and DVT.Introduction:
Materials and Methods:
Herniation pits had been considered as a normal variant, a cystic lesion formed by synovial invagination. On the contrary, it was also suggested that herniation pits were one of the diagnostic findings in femoroacetabular impingement (FAI) because of the high prevalence of herniation pits in the FAI patients. To date, the exact etiology is still unknown. The purpose of this study was to evaluate whether there is an association between the presence of herniation pits and morphological indicators of FAI based on computed tomography (CT) examination. We reviewed the CT scans of 245 consecutive subjects (490 hips, age: 21–89 years) who had undergone abdominal and pelvic CT for reasons unrelated to hip symptom from September, 2010 to June, 2011. These subjects were mainly examined for abdominal disorders. We confirmed by the questionnaire survey that there were no subjects who had symptoms of hip joints. We reviewed them for the presence of herniation pits and the morphological abnormalities of the femoral head and acetabulum. Herniation pits were diagnosed when they were located at the anterosuperior femoral head-neck junction with a diameter of more than 3 mm. We measured following four signs as indicators for FAI: α angle, center edge angle (CE angle), acetabular index (AI), and acetabular version. Mann-Whitney U-test was used for statistical analysis.Introduction
Materials and methods
Primary internal fixation of uncomplicated scaphoid fractures is growing in popularity due to its advantages over conventional cast fixation. Performing the procedure percutaneously reduces the risk of infection and soft tissue damage, but can be tricky because of the small size and complex three-dimensional (3D) shape of this bone. Computer-assisted navigation has been an invaluable tool in other pin insertion procedures. This in-vitro study aimed to evaluate two different rendering techniques for our navigation interface: (i) 3D volume rendering of the CBCT image to show digitally-reconstructed radiographs of the anatomy, and (ii) volume-slicing, analogous to CT-images. As the shape of the scaphoid is highly variable, a plastic model of the wrist was constructed in order to provide consistency that would not be possible in a cadaver-based study. The plastic model featured a removable scaphoid such that a new one was replaced between trials. Three surgeons each performed eight trials using each of the two navigated techniques (yielding a total of 48 trials for analysis). Central placement of scaphoid fixation has been linked with mechanical stability and improved clinical outcomes, thus the surgical goal was to place a K-wire to maximise both depth from the surface and length of the drill path. The wire was drilled through the scaphoid, from distal to proximal, allowing for post-trial analysis of the drill path. A ceiling-mounted OptoTrak Certus camera (Northern Digital Inc., Canada) and a floor-mounted isocentric 3D CBCT C-arm (Innova 4100, GE Healthcare, France) permitted a registration transformation between the tracking and imaging systems to be computed preoperatively, before each trial, using a custom calibration device. Optical local coordinate reference bodies were attached to the wrist model and a custom drill guide for tracking with the Certus camera. During each trial, a 3D spin image of the wrist model was acquired, and rendered according to the technique under study. For 3D volume rendering, the spin image was rendered as a digitally-reconstructed radiograph (DRR) that could be rotated in three dimensions. In the planning phase, the surgeon positioned a desired drill path on the images. Anterior-posterior and lateral views of the 3D volume rendering were used for navigation during the drilling phase. The real-time orientation of the drill guide was shown relative to these images and the plan on an overhead. For volume-sliced (VS) navigation, the spin image was volume-rendered and sliced along the principal planes (axial, coronal, sagittal) for planning. A slider interface allowed the surgeon to scroll through the slices in each of the planes, as if they were looking at individual CT slices. Once the desired drill path was positioned, the volume-sliced views were reconfigured to show slices along the oblique planes of the planned path for navigation. Following all trials, model scaphoids with wire intact were imaged using CT with a slice thickness of 0.625 mm. The CT series were segmented and used to construct 3D digital models of the wire and drilled scaphoid. Algorithms were developed to determine the minimum distance from the centerline of the wire and the scaphoid surface, and to compute the length of the drill path. Screw breach should be avoided as it disrupts the articular surface and may lead to a sequela of cartilage deterioration and osteoarthritic changes. The shortest distance measure was extrapolated to assess whether a standard fixation screw (Accutrak Mini, 1.78 mm radius) would have breached the scaphoid surface. There were three screw breaches noted in the 3D DRR trials, while only one occurred using volume-slicing. The minimum distance from the centerline of the wire to the scaphoid surface can also be thought of as a “safe zone” for screw breach. Although no difference in the mean distance (μ) was noted between groups (μDRR = 2.3 mm, μVS = 2.2 mm), the standard deviation (σ) was significantly higher for the DRR trials (σDRR = 0.50 mm, σVS = 0.37 mm, p < 0.1), suggesting a higher reliability of central placement using VS for navigation. In contrast, the length of the drill paths were significantly longer for the DRR trials (μ = 28.7 mm, σ = 0.66 mm) than for VS-navigation (μ = 28.3 mm, σ = 0.62 mm) at p < 0.1. The surgical goal was to pick a path that maximised both the length of the path, as well as the minimum distance from the scaphoid surface. Algorithms were developed to find the paths that would maximise: (i) the length and (ii) the distance from the surface of the model scaphoid used in this study. The maximum possible length was 29.8mm (with a minimum distance of 2.2mm from the scaphoid surface), and the maximum distance was 3.3mm (with a length of 27.5mm). Therefore, the set of optimal drill paths had length > 27.5 mm, and distance > 2.8 mm. Of the DRR-navigated trials, 11 were below the minimum optimal depth, and only one trial was below the optimal length; 13 of the 24 trials (54%) were of both optimal length and depth. Of the VS-navigated trials, nine were below the minimal optimal distance, and four were below the minimum optimal length; 11 out of 24 trials (46%) were within both the optimal length and depth. From this comparative study, we conclude that VS-navigation was superior in locating a central location for the fixation wire, while DRRs were superior in maximising the depth of the drill path. Thus, we propose a hybrid interface, incorporating both volume-slicing and DRRs, in order to maximise the effectiveness of navigation for percutaneous scaphoid pinning.
The medial and lateral Böhler angles were measured on plain x-rays. The analysis included search for a double line on the posterior talocalcaneal facet, secondary body displacement, the position of the oblique screw and the degree of posttraumatic subtalar wear. The clinical criteria established in the 1988 SOFCOT guidelines were recorded. Analysis of variance, Pearson and Spearman coefficients, and RIDITS analysis (the most powerful method available for evidencing a relationship between two qualitative variables one of which is ordinal) were used to search for prognostic elements and correlations.
Pedicle screws allow for biomechanically secure fixation of the spine. However if they are misplaced they may effect the strength of the fixation, damage nerve roots or compromise the spinal cord. For these reasons image guidance systems have been developed to help with the accuracy of screw placement. The accuracy of pedicle screw placement outside the lumbar spine is not well published. To determine the accuracy of pedicle screw placement using CT scanning post operatively. Cortex perforations were graded in 2mm steps. Prospective observational study. Plain x-rays are inaccurate for determining screw placement and therefore high definition CT scanning was used. The screw positioning on the post-operative CT scans was independently determined by a research registrar who was not present at the time of surgery. Screw position and clinical sequelae of any malposition. Thirty patients (13 F:17 M) with segmental instability. Twelve were for metastatic disease, seven for trauma, seven for spondylolisthesis, three for atlanto-axial instability and one for a vertebral haemangioma. All patients were operated on by the senior author. One hundred and seventy six pedicle screws were inserted in the thirty patients over the 20 month study period. Six screws violated the lateral cortex of the pedicle but none perforated the medial cortex. There were no adverse neurological sequelae. The findings from this study will serve as a good comparison with future studies on pedicle screw placement, which may claim to improve accuracy and safety by the use of image guidance systems, electrical impedance or malleable endoscopes.
All lesions occurred around the prosthetic rim, and the mean size of osteolysis per knee was 2.1 +/−1.5 cc (range, 0.4–4.7 cc). Only seven lesions in 6 knees were diagnosed as osteolysis on plain radiographs: 2 lesions at anterior femoral condyle and 5 lesions at tibial condyles. None of the lesions around the posterior condylar flanges detected on CT was identified on plain radiographs. None of the implants showed radiographic loosening or required reoperation.
Although we often encounter patients with an aortic aneurysm
who also have diffuse idiopathic skeletal hyperostosis (DISH), there
are no reports to date of an association between these two conditions
and the pathogenesis of DISH remains unknown. This study therefore
evaluated the prevalence of DISH in patients with a thoracic aortic
aneurysm (AA). The medical records of 298 patients who underwent CT scans for
a diagnosis of an AA or following high-energy trauma were retrospectively
examined. A total of 204 patients underwent surgery for an AA and
94 had a high-energy injury and formed the non-AA group. The prevalence
of DISH was assessed on CT scans of the chest and abdomen and the
relationship between DISH and AA by comparison between the AA and
non-AA groups.Aims
Patients and Methods
In recent years, some attempts have been made to develop a method that generates finite element (FE) models of the femur and pelvis using CT. However, due to the complex bone geometry, most of these methods require an excessive amount of CT radiation dosage. Here we describe a method for generating accurate patient-specific FE models of the total hip using a small number of CT scans in order to reduce radiation exposure. A previously reported method for autogenerating patient-specific FE models of the femur was extended to include the pelvis. CT osteodensitometry was performed on 3 patients who had hip replacement surgery and patient-specific FE models of the total hip were generated. The pelvis was generated with a new technique that incorporated a mesh morphing method called ‘host mesh fitting’. It used an existing generic mesh and then morphed it to reflect the patient specific geometry. This can be used to morph the whole pelvis, but our patient dataset was limited to the acetabulum. An algorithm was developed that automated all the procedures involved in the fitting process. Average error between the fitted mesh and patient specific data sets for the femur was less than 1mm. The error for the pelvis was about 2.5mm. This was when a total 18 CT scans with 10mm gap were used – 12 of the femur, and 6 of the pelvis. There was no element distortion and a smooth element surface was achieved. Previously, we reported a new method for automatically generating a FE model of the femur with as few CT scans as possible. Here we describe a technique that customizes a generic pelvis mesh to patient-specific data sets. Thus we have developed a novel hybrid technique which can generate an accurate FE model of the total hip using significantly less CT scans. An automated method of generating FE models for the total hip with reduced CT radiation exposure will be a valuable clinical tool for surgeons.
This study identified imaging parameter(s) which best predict the mechanical properties of distal tibia. Seventeen human cadaver tibiae were assessed by PQCT at four, eight and ten percent site from distal and tested in compression at the twenty-five percent distal portion. Ultimate compressive loads were recorded with a mean of 8276 ± 2915 N. Spearson rank correlation and stepwise regression analysis revealed that CoA, total BMC, SSI and SSI4-TrA4-CoD4 combination had statistically significant correlations with the failure loads. Among all imaging parameters, SSI had the highest relevance due to its account for geometry, density and material distribution, important factors for structural properties. Musculoskeletal diseases, especially hip fractures, have huge and growing impact on Canadian society. To develop techniques for identification of high risk population, we needed a link between clinical evaluations and laboratory measures of bone health. This study identified imaging parameter(s) which best predict the mechanical properties of distal tibia. Seventeen human cadaver tibiae were considered in this study (mean age seventy-four, SD six years). PQCT was used to assess the four, eight and ten percent site. It measured the cross-sectional area, bone mineral content and bone mineral density of the cortical bone, trabecular bone and combined. Strength Strain Index (SSI) was calculated from these measurements. Each tibia was cut at twenty-five percent distal. Compressive force was applied uniaxially through a custom-made PMMA indentor onto the distal plateau along the longitudinal axis of the tibia at a rate of 10mm/s. Load and displacement data were recorded. Spearson rank correlation and stepwise regression analysis were used to identify individual and combination of imaging variables that were related to ultimate failure load. Ultimate failure loads were recorded with a mean of 8276 ± 2915 N. Cortical area (R_0.72), total BMC (R_0.72) and SSI (R_0.86) had statistically significant correlations with the failure load. Stepwise regression revealed that the combination of SSI, TrA, CoD at 4% site explained the greatest amount of variance (R2 = 0.868) and SSI was the major contributor. SSI takes the polar moment of inertia (geometry), density and distribution of material into account. This explains its relevance towards predicting the ultimate failure load. Please contact author for referenced images
In recent years, some attempts have been made to develop a method that generates finite element (FE) models of the femur and pelvis using CT. However, due to the complex bone geometry, most of these methods require an excessive amount of CT radiation dosage. Here we describe a method for generating accurate patient-specific FE models of the total hip using a small number of CT scans in order to reduce radiation exposure. A previously reported method for autogenerating patient-specific FE models of the femur was extended to include the pelvis. CT osteodensitometry was performed on 3 patients who had hip replacement surgery and patient-specific FE models of the total hip were generated. The pelvis was generated with a new technique that incorporated a mesh morphing method called ‘host mesh fitting’. It used an existing generic mesh and then morphed it to reflect the patient specific geometry. This can be used to morph the whole pelvis, but our patient dataset was limited to the acetabulum. An algorithm was developed that automated all the procedures involved in the fitting process. Average error between the fitted mesh and patient specific data sets for the femur was less than 1mm. The error for the pelvis was about 2.5mm. This was when a total 18 CT scans with 10mm gap were used – 12 of the femur, and 6 of the pelvis. There was no element distortion and a smooth element surface was achieved. Previously, we reported a new method for automatically generating a FE model of the femur with as few CT scans as possible. Here we describe a technique that customizes a generic pelvis mesh to patient-specific data sets. Thus we have developed a novel hybrid technique which can generate an accurate FE model of the total hip using significantly less CT scans.
Intraobserver reliability of the OTA/AO classification was good with plain radiographs (k=0,70) and improved to excellent after adding three-dimensional SSD reconstructions (k=0,80) and three-dimensional VR reconstructions (k=0,88). Interobserver reliability of the Neer classification was poor with plain radiographs (k=0,39) and moderate with two-dimensional CT scans and conventional three-dimensional (SSD) reconstructions (k=0,56) and improved to good with the addition of 3D VR scans (k=0,74). Intraobserver reliability for was poor with plain radiographs (k=0,34), good with three-dimensional SSD reconstructions (k=0,61), and excellent with three-dimensional VR reconstructions (k=0,80).
The aim of this study was to analyse the effect of altered viewing
perspectives on the measurement of the glenopolar angle (GPA) and
the differences between these measurements made on 3D CT reconstructions
and anteroposterior (AP) scapular view radiographs. The influence of the viewing perspective on the GPA was assessed,
as were the differences in the measurements of the GPA between 3D
CT reconstructions and AP scapular view radiographs in 68 cadaveric
scapulae.Aims
Materials and Methods
Femoroacetabular impingement (FAI) has been highlighted and well
documented primarily in Western countries and there are few large
studies focused on FAI-related morphological assessment in Asian
patients. We chose to investigate this subject. We assessed the morphology of the hip and the prevalence of radiographic
FAI in Japanese patients by measuring predictors of FAI. We reviewed
a total of 1178 hips in 695 men and 483 women with a mean age of
58.2 years (20 to 89) using CT images that had been obtained for
reasons unrelated to symptoms from the hip. We measured the lateral
centre edge angle, acetabular index, crossover sign, alpha angle
and anterior femoral head-neck offset ratio.Aims
Patients and Methods
Patient-specific glenoid guides (PSGs) claim an improvement in
accuracy and reproducibility of the positioning of components in
total shoulder arthroplasty (TSA). The results have not yet been
confirmed in a prospective clinical trial. Our aim was to assess
whether the use of PSGs in patients with osteoarthritis of the shoulder
would allow accurate and reliable implantation of the glenoid component. A total of 17 patients (three men and 14 women) with a mean age
of 71 years (53 to 81) awaiting TSA were enrolled in the study.
Pre- and post-operative version and inclination of the glenoid were
measured on CT scans, using 3D planning automatic software. During
surgery, a congruent 3D-printed PSG was applied onto the glenoid
surface, thus determining the entry point and orientation of the
central guide wire used for reaming the glenoid and the introduction
of the component. Manual segmentation was performed on post-operative
CT scans to compare the planned and the actual position of the entry
point (mm) and orientation of the component (°).Aims
Patients and Methods
We investigated the blood flow to the femoral head during and after Resurfacing Arthroplasty of the hip. In a previous study, we recorded the intra-operative blood flow in 12 patients who had a posterior approach to the hip and 12 who had a trochanteric flip approach. Using a LASER Doppler flowmeter, we found a 40% drop in blood flow in the posterior group and an 11% drop in the trochanteric flip group (p<0.001). The aim of this current study was to find out whether the intra-operative fall in blood flow persists during the post-operative period. We therefore conducted a Single Positron Emission Tomography (SPECT) scan on 14 of the same group of patients. The proximal femur was divided into four regions of interest. These were the mid-shaft, proximal shaft, inter-trochanteric and head-neck regions. The data was analysed for bone activity and comparisons made between the two groups for each region of the femur. We found that the bone activity in the mid-shaft, upper-shaft, and head-neck regions was the same eleven months after the surgery irrespective of the approach to the hip. However there was higher activity in the trochanteric flip group in the inter-trochanteric region. We conclude that the intra-operative deficit in blood flow to the head-neck region of the hip associated with the posterior approach does not seem to persist in the late post-operative period. We believe the reason for increased bone activity in inter-trochanteric region to be due to the healing of the trochanteric flip osteotomy.
The clinical utility of routine cross sectional imaging of the
abdomen and pelvis in the screening and surveillance of patients
with primary soft-tissue sarcoma of the extremities for metastatic
disease is controversial, based on its questionable yield paired
with concerns regarding the risks of radiation exposure, cost, and
morbidity resulting from false positive findings. Through retrospective review of 140 patients of all ages (mean
53 years; 2 to 88) diagnosed with soft-tissue sarcoma of the extremity
with a mean follow-up of 33 months (0 to 291), we sought to determine
the overall incidence of isolated abdominopelvic metastases, their
temporal relationship to chest involvement, the rate of false positives, and
to identify disparate rates of metastases based on sarcoma subtype.Objectives
Methods
The objective of this study was to evaluate the rotation and
translation of each joint in the hindfoot and compare the load response
in healthy feet with that in stage II posterior tibial tendon dysfunction
(PTTD) flatfoot by analysing the reconstructive three-dimensional
(3D) computed tomography (CT) image data during simulated weight-bearing. CT scans of 15 healthy feet and 15 feet with stage II PTTD flatfoot
were taken first in a non-weight-bearing condition, followed by
a simulated full-body weight-bearing condition. The images of the
hindfoot bones were reconstructed into 3D models. The ‘twice registration’
method in three planes was used to calculate the position of the
talus relative to the calcaneus in the talocalcaneal joint, the
navicular relative to the talus in talonavicular joint, and the cuboid
relative to the calcaneus in the calcaneocuboid joint.Objective
Methods
We investigated the development of CT-based bony
radiological parameters associated with femoroacetabular impingement
(FAI) in a paediatric and adolescent population with no known orthopaedic
hip complaints. We retrospectively reformatted and reoriented
225 abdominal CTs into standardised CT pelvic images with neutral
pelvic tilt and inclination (244 female and 206 male hips) in patients
ranging from two to 19 years of age (mean 10.4 years). The Tönnis
angle, acetabular depth ratio, lateral centre–edge angle, acetabular
version and α-angle were assessed. Acetabular measurements demonstrated increased acetabular coverage
with age and/or progressive ossification of the acetabulum. The α-angle
decreased with age and/or progressive cortical bone development
and resultant narrowing of the femoral neck. Cam and pincer morphology
occurred as early as ten and 12 years of age, respectively, and
their prevalence in the adolescent patient population is similar
to that reported in the adult literature. Future aetiological studies
of FAI will need to focus on the early adolescent population. Cite this article:
This study aims to assess the correlation of CT-based structural
rigidity analysis with mechanically determined axial rigidity in
normal and metabolically diseased rat bone. A total of 30 rats were divided equally into normal, ovariectomized,
and partially nephrectomized groups. Cortical and trabecular bone
segments from each animal underwent micro-CT to assess their average
and minimum axial rigidities using structural rigidity analysis.
Following imaging, all specimens were subjected to uniaxial compression
and assessment of mechanically-derived axial rigidity.Objectives
Methods
The aim of this study was to investigate the effect of different loading scenarios and foot positions on the configuration of the distal tibiofibular joint (DTFJ). Fourteen paired human cadaveric lower legs were mounted in a loading frame.
Objective. The purpose of this study was to determine the outcomes of revision ankle replacements, using the Invision implant and impaction allograft for massive talar dome defects following primary ankle replacement failure. Outcomes were assessed in terms of bone graft incorporation; improvement in patient reported outcome measures (PROMs); and survivorship of the revision ankle arthroplasty. Methods. A retrospective review of prospectively collected data identified eleven patients who had massive bone cysts and underwent revision of a failed primary total ankle replacement to the Invision revision system, combined with impaction grafting using morselized femoral head allograft. These revisions occurred at a single high volume ankle arthroplasty centre.
Orthopaedic injuries in the knee are often associated with vascular injury. When these vascular injuries are missed devastating there are devastating outcomes like limb ablation. Pulse examination in these patients is not sensitive to exclude vascular injuries. That often lead to clinicians opting for
Abstract. Introduction. Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures, used for the management of end-stage arthritis. With the recent introduction of robotic assisted joint replacement,
Aim. Magnetic resonance imaging (MRI) and 2-[. 18. F]-fluoro-2-deoxy-D-glucose (. 18. F-FDG) Positron Emission Tomography, paired with
Acetabular morphology and orientation differs from ethnic group to another. Thus, investigating the natural history of the parameters that are used to assess both was a matter of essence. Nevertheless, clarification the picture of normal value in our society was the main aim of this study. However, Acetabular head index (AHI) and center edge angle (CEA) were the most sensitive indicative parameters for acetabular dysplasia. Hence, they were the main variables used in evaluation of acetabular development. A cross-sectional retrospective study that had been done in a tertiary center.
Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement,
Aims. Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications. Methods. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with