Background. Dislocation is a common complication after proximal and total femur prosthesis reconstruction for primary bone sarcoma patients. Expandable prosthesis in children puts an additional challenge due to the lengthening process. Hip stability is impaired due to multiple factors: Resection of the hip stabilizers as part of the sarcoma resection: forces acts on the hip during the lengthening; and mismatch of native growing acetabulum to the metal femoral head. Surgical solutions described in literature are various with reported low rates of success. Objective. Assess a novel 3D surgical planning technology by use of 3D models (computerized and physical), 3D planning, and Patient Specific Instruments (PSI) in supporting correction of young children suffering from hip instability after expandable prosthesis reconstruction following proximal femur resection. This innovative technology creates a new dimension of visualization and customization, and could improve understanding of this complex problem and facilitate the surgical decision making and procedure. Method. Two children, both patients with Ewing Sarcoma of the left proximal femur stage-IIB, ages 3/5 years at diagnosis, were treated with conventional chemotherapy followed by proximal femur resection. Both were reconstructed with expandable prosthesis (one at resection and other 4 years after resection). Hip migration developed gradually during lengthening process in the 24m follow up period. 3D software (Mimics, Materialise, Belgium) were used to make computerized 3D models of patients' pelvises. These were used to 3D print 1:1 physical models. Custom 3D planning software (MSk Lab, Imperial College London) allowed surgeons visualizing the anatomical status and assess of problem severity. Thereafter, osteotomies planes and the desired position of acetabular roof after reduction of hip joint were planned by the surgeons. These plans were used to generate 3D printed PSIs to guide the osteotomies during shelf and triple osteotomy surgeries. Accuracy of planning and PSIs were verified with fluoroscopy and post-op X-rays, by comparing cutting planes and post-op position of the acetabulum. Results. Surgeons reported excellent experience with the 3D models (computerized and physical). It helped them in the decision process with an improved understanding of the relationship between prosthesis head and acetabulum, a clear view of the osteophytes and bone formation surrounding the pseudoacetabulum, and osteophytes inside the native acetabulum. These osteophytes were not immediately visible on 2D CT imaging slices. Surgeons reported a good fit and PSIs' simplicity of use. The hip stability was satisfactory during surgery and in the immediate post-op period. X-ray showed a good and centered position of the hip and good levels of the osteotomies. Conclusions. 3D surgical planning and 3D printing was found to be very effective in assisting surgeons facing complex problems. In these particular cases neither CT nor MRI were able to visualize all bony formation and entrapment of prosthesis in the pseudoacetabulum. 3D visualisation can be very helpful for surgical treatment decisions, and by planning and executing surgery with the guidance of PSIs, surgeons can improve their surgical results. We believe that 3D technology and its advantages, can improve success rates of hip stability in this unique cohort of patients

Introduction. In the evaluation of patients with pre-arthritic hip disorders, making the correct diagnosis and identifying the underlying bone pathology is of upmost importance to achieve optimal patient outcomes. 3-dimensional imaging adds information for proper preoperative planning. CT scans have become the gold standard for this, but with the associated risk of radiation exposure to this generally younger patient cohort. Purpose. To determine if 3D-MR reconstructions of the hip can be used to accurately demonstrate femoral and acetabular morphology in the setting of femoroacetabular impingement (FAI) and development dysplasia of the hip (DDH) that is comparable to CT imaging. Materials and Methods. We performed a retrospective review of 14 consecutive patients with a diagnosis of FAI or DDH that underwent both CT and MRI scans of the same hip with 3D reconstructions. 2 fellowship trained musculoskeletal radiologists reviewed all scans, and a fellowship trained hip preservation surgeon separately reviewed scans for relevant surgical parameters. All were blinded to the patients' clinical history. The 3D reconstructions were evaluated by radiologists for the presence of a CAM lesion and acetabular retroversion, while the hip preservation surgeon also evaluated CAM extent using a clock face convention of a right hip, location of femoral head blood supply, and morphological anterior inferior iliac spine (AIIS) variant. The findings on the 3D CT reconstructions were considered the reference standard. Results. Of 14 patients, there were 9 females and 5 males with a mean age 32 (range 15–42). There was no difference in the ability of MRI to detect the presence of a CAM lesion (100% agreement between 3D-MR and 3D-CT, p=1), AIIS morphology (p=1, mode=type 1 variant), or acetabular retroversion (85.7%, p=0.5). 3D-MR had a sensitivity and specificity of 100 in detecting a CAM lesion relative to 3D-CT. Four CT studies were inadequate to adequately evaluate for presence of a CAM. Five CT studies were inadequate to evaluate for location of the femoral head vessels, while MRI was able to determine location in those patients. In the 10 remaining patients for presence of CAM, and nine patients for femoral head vessel location, there was no statistically significant difference between 3D-MR and 3D-CT in determining the location of CAM lesion on a clock face (p=0.8, mean MRI = 12:54, mean CT: 12:51, SD = 66 mins MR, 81 mins CT) or in determining vessel location (p=0.4, MR mean 11:23, CT mean 11:36, SD 33 mins for both). Conclusion. 3D MRI reconstructions are as accurate as 3D CT reconstructions in evaluating osseous morphology of the hip, and may be superior to CT in determining other certain clinically relevant hip parameters. 3D-MR was equally useful in determining the presence and extent of a CAM lesion, acetabular retroversion, and AIIS morphologic variant, and more useful than 3D CT in determining location of the femoral head vessels. In evaluating FAI or hip dysplasia, a 3D-MR study is sufficient to evaluate both soft tissue and osseous anatomy, sparing the need for a 3D CT scan and its associated radiation exposure and cost

3D printing techniques have attracted a lot of curiosity in various surgical specialties and the applications of the 3D technology have been explored in many ways including fracture models for education, customized jigs, custom implants, prosthetics etc. Often the 3D printing technology remains underutilized in potential areas due to costs and technological expertise being the perceived barriers. We have applied 3D printing technology for acetabular fracture surgeries with in-house, surgeon made models of mirrored contralateral unaffected acetabulum based on the patients’ trauma CT Scans in 9 patients. The CT Scans are processed to the print with all free-ware modeling software and relatively inexpensive printer by the surgeon and the resulting model is used as a ‘reduced fracture template’ for pre-contouring the standard pelvic reconstruction plates. This allows use of the standard surgical implants, saves time on intra-operative plate contouring, and also aids in reduction to an extent. We share through this presentation the workflow of the freeware softwares to use in order to use this surgical planning and implant preparation that may remove the perceived barriers of cost and technology from surgeons that wish to explore using 3D printing technology for acetabular fracture management and may extend applications to other regions

Anatomically specific fixation devices have become mainstream, yet there are anatomical regions and clinical conditions where no pre-contoured plates are available, such as for glenohumeral arthrodesis. In a case series of 4 glenohumeral arthrodesis patients, a consultant orthopaedic surgeon at GCUH implemented 3D printing technology to create reconstructions of each patient's shoulder girdle to pre-contour arthrodesis plates. Our aim was to quantify the cost-benefit & intra-operative time savings of this technique in glenohumeral arthrodesis. We hypothesized that the use of 3D printing for creating patient specific implants through pre-operative contouring of plates will lead to intra-operative time and cost savings by minimising time spent bending plates during surgery. This study analysed 4 patients who underwent shoulder arthrodesis by a single consultant orthopaedic surgeon at GCUH between 2017-2021. A CT-based life-size model of each patient's shoulder girdle was 3D printed using freely available computer software programs: 3D Slicer, Blender, Mesh Mixer & Cura. Once the patient's 3D model was created, plate benders were used to contour the plate pre-op, which was then sterilised prior to surgery. Arthrodesis was performed according to AO principles of fixation. The time spent pre-bending the plate using the 3D model was calculated to analyse the intra-op time and cost-saving benefits. For the 4 cases, the plate pre-bending times were 45, 40, 45 & 20 minutes (average 38.8 mins). The intra-op correction time to make small adjustments to the plate was 2 min/ case. 3 plates needed minor (3 degree) adjustment to fine-tune scapula spine contouring. 1 plate needed a 5 degree correction to fine-tune hand position. On average, the pre-bending of the plate saved approximately 38.8 mins intra-op/ case. These shorter anaesthetic and operating times equate to approximately $2586 saving/ case, given an estimate of $4000/hour of theatre costs. We conclude that pre-bending plates around 3D-printed life-size models of an individual's shoulder girdle prior to surgery results in approximately 38.8 mins time saving intra-op when used in shoulder arthrodesis. This is a viable and effective technique that will ultimately result in significant operative time and financial savings

Cup position planning for total hip replacement (THR) is a complex task which is influenced by several factors. Whereas aspects like appropriate implant fixation and bone stock preservation are rather evaluated according to intra-operative findings, functional analyses using biomechanical hip models can rely on pre-operative imaging. Due to the wide availability and cost-efficiency of X-ray imaging technology along with the common restriction of biomechanical evaluations to the frontal plane, pre-operative imaging for such purposes is usually limited to AP radiographs. One example is biomechanical optimisation based on the so-called BLB score, which has already been introduced into clinical practice. In this approach, the assumed suitability of potential hip centres of rotation (CORs) is presented to the surgeon by applying colour-coding within the pre-operative AP radiograph. However, to realise the plan, the surgeon has to transfer the 2D positions presented in the radiograph into the 3D surgical site. We developed a CT-based simulation tool allowing for the generation of 3D bone surface models as well as standardised digitally reconstructed radiographs (DRRs). Within a 3D view, the cup, which is represented as a hemisphere, can freely be shifted in the coronal plane. The 2D point corresponding to the COR defined by the hemisphere is then automatically computed. In our study, four CT datasets of hips with large bony defects were used. After segmentation 3D bone surface models were generated. These bone surface models were aligned on the basis of the pelvic coordinate system [3], and standardised AP DRRs were computed. BLB score evaluation in intact hips assumes that the central beam passes through the centroid of both hip CORs. As only the contra-lateral hip COR was available due to the defects, a virtual ipsi-lateral COR was obtained by mirroring the contra-lateral hip across the mid-sagittal plane. Twelve surgeons (divided into two groups of six each according to their experience) had the task to shift the cup such that its 3D position would best match a predefined 2D target position, which was close to the virtual ipsi-lateral COR and displayed as a cross within the standardised DRR. However, the current 2D position corresponding to the current 3D position was not revealed during positioning. Once the user was satisfied with the 3D position, the corresponding 2D position was recorded. The following results were obtained (mean ± SD across six surgeons of the respective group) for the four patients:. x-error, more experienced: 2.0 ± 6.1; −3.0 ± 5.9; 4.1 ± 4.8; 2.1 ± 5.2; x-error, less experienced: 4.3 ± 4.2; −3.1 ± 1.8; 1.9 ± 4.0; 5.2 ± 4.1; |x-error|, more experienced: 5.2 ± 3.0; 5.4 ± 3.2; 5.5 ± 2.7; 4.3 ± 3.0;|x-error|, less experienced: 4.3 ± 4.2; 3.1 ± 1.8; 3.3 ± 2.7; 5.7 ± 3.3; y-error, more experienced: 12.0 ± 9.1; 0.3 ± 4.3; 6.2 ± 6.6; 1.9 ± 3.2;. y-error, less experienced: 6.1 ± 3.1; 0.8 ± 4.0; 2.4 ± 5.5; 1.4 ± 4.1;|y-error|, more experienced: 12.0 ± 9.1; 3.2 ± 2.6; 6.2 ± 6.6; 3.0 ± 1.9;|y-error|, less experienced: 6.1 ± 3.1; 3.4 ± 1.6; 4.6 ± 3.3; 3.2 ± 2.6;total error, more experienced: 13.5 ± 8.9; 6.6 ± 3.5; 9.8 ± 4.1; 5.4 ± 3.4;total error, less experienced: 8.5 ± 2.7; 4.9 ± 1.5; 6.5 ± 2.5; 6.7 ± 3.8. Our experimental results show that mental 2D/3D matching for cup positioning in pelvises with bony defects is a difficult task, and that mental 2D/3D matching cannot be expected to yield the correct 3D cup positions corresponding to positions predefined in radiographs. The largest errors were found in the patient with the lowest image quality suggesting that image quality plays an important role. On contrary, experience was not found to be an important factor. We believe that in clinical practice mental 2D/3D matching between pre-operative radiographs and the surgical site without the help of 3D imaging or special tools would be more difficult than the task given in this study because only small portions of the pelvis would be exposed. Furthermore, as additional aspects of cup positioning would need to be taken into consideration simultaneously, the mental load could be expected to be higher. We conclude that in hips with large bony defects cup positioning based on pre-operative radiographs is highly unreliable without additional computer-assistance or intra-operative imaging. If pre-operative radiographs are needed for functional analyses, combination with 3D image data seems attractive: Firstly, 3D images can easily be used for navigation; secondly, they allow for the generation of highly standardised views, which is essential for comparability across multiple patients. Future studies relying on more datasets with a wider range of defects could also investigate whether cranio-caudal or medio-lateral positioning errors prevail. This is an interesting question since the BLB score usually is much more specific in the medio-lateral direction than in the cranio-caudal direction, implying that correct 2D/3D matching for the cranio-caudal direction appears less important. In the current study involving only four hips, however, no clear tendency could be observed. This work has been funded in part by the German Ministry for Education and Research (BMBF) in the framework of the orthoMIT project under grant No. BMBF 01EQ0802/BMBF 01IBE02C

Glenoid baseplate positioning for reverse total shoulder replacements (rTSR) is key for stability and longevity. 3D planning and image-derived instrumentation (IDI) are techniques for improving implant placement accuracy. This is a single-blinded randomised controlled trial comparing 3D planning with IDI jigs versus 3D planning with conventional instrumentation. Eligible patients were enrolled and had 3D pre-operative planning. They were randomised to either IDI or conventional instrumentation; then underwent their rTSR. 6 weeks post operatively, a CT scan was performed and blinded assessors measured the accuracy of glenoid baseplate position relative to the pre-operative plan. 47 patients were included: 24 with IDI and 23 with conventional instrumentation. The IDI group were more likely to have a guidewire placement within 2mm of the preoperative plan in the superior/inferior plane when compared to the conventional group (p=0.01). The IDI group had a smaller degree of error when the native glenoid retroversion was >10° (p=0.047) when compared to the conventional group. All other parameters (inclination, anterior/posterior plane, glenoids with retroversion <10°) showed no significant difference between the two groups. Both IDI and conventional methods for rTSA placement are very accurate. However, IDI is more accurate for complex glenoid morphology and placement in the superior-inferior plane. Clinically, these two parameters are important and may prevent long term complications of scapular notching or glenoid baseplate loosening. Image-derived instrumentation (IDI) is significantly more accurate in glenoid component placement in the superior/inferior plane compared to conventional instrumentation when using 3D pre-operative planning. Additionally, in complex glenoid morphologies where the native retroversion is >10°, IDI has improved accuracy in glenoid placement compared to conventional instrumentation. IDI is an accurate method for glenoid guidewire and component placement in rTSA

3D printing and Bioprinting technologies are becoming increasingly popular in surgery to provide a solution for the regeneration of healthy tissues. The aim of our project is the regeneration of articular cartilage via bioprinting means, to manage isolated chondral defects. Chrondrogenic hydrogel (chondrogel: GelMa + TGF-b3 and BMP6) was prepared and sterilised in our lab following our standard protocols. Human adipose-derived mesenchymal stem cells were harvested from the infrapatellar fat pad of patients undergoing total knee joint replacements and incorporated in the hydrogel according to our published protocols. The chondrogenic properties of the chondrogel have been tested (histology, immunohistochemistry, PCR, immunofluorescence, gene analysis and 2. nd. harmonic generation microscopy) in vitro and in an ex-vivo model of human articular defect and compared with standard culture systems where the growth factors are added to the media at repeated intervals. The in-vitro analysis showed that the formation of hyaline cartilage pellet was comparable between the two strategies, with a similar metabolic activity of the cells. These results have been confirmed in the ex-vivo model: hyaline-like cartilage was observed within the chondral defect in both the chondrogel group and the control group after 28 days in culture. The use of bioprinting techniques in vivo requires the ability of stem cells to access growth factors directly in the environment they are in, as opposed to in vitro techniques where these factors are provided externally at recurrent intervals. This study showed the successful strategy of incorporating chondrogenic growth factors for the formation of hyaline-like cartilage in vitro and in an ex-vivo model of chondral loss. The incorporation of chondrogenic growth factors in a hydrogel is a possible strategy for articular cartilage regeneration

The opposable thumb is one of the defining characteristics of human anatomy and is involved in most activities of daily life. Lack of optimal thumb motion results in pain, weakness, and decrease in quality of life. First carpometacarpal (CMC1) osteoarthritis (OA) is one of the most common sites of OA. Current clinical diagnosis and monitoring of CMC1 OA disease are primarily aided by X-ray radiography; however, many studies have reported discrepancies between radiographic evidence of CMC1 OA and patient-related outcomes of pain and disability. Radiographs lack soft-tissue contrast and are insufficient for the detection of early characteristics of OA such as synovitis, which play a key role in CMC OA disease progression. Magnetic resonance imaging (MRI) and two-dimensional ultrasound (2D-US) are alternative options that are excellent for imaging soft tissue pathology. However, MRI has high operating costs and long wait-times, while 2D-US is highly operator dependent and provides 2D images of 3D anatomical structures. Three-dimensional ultrasound imaging may be an option to address the clinical need for a rapid and safe point of care imaging device. The purpose of this research project is to validate the use of mechanically translated 3D-US in CMC OA patients to assess the measurement capabilities of the device in a clinically diverse population in comparison to MRI. Four CMC1-OA patients were scanned using the 3D-US device, which was attached to a Canon Aplio i700 US machine with a 14L5 linear transducer with a 10MHz operating frequency and 58mm. Complimentary MR images were acquired using a 3.0 T MRI system and LT 3D coronal photon dense cube fat suppression sequence was used. The volume of the synovium was segmented from both 3D-US and MR images by two raters and the measured volumes were compared to find volume percent differences. Paired sample t-test were used to determine any statistically significant differences between the volumetric measurements observed by the raters and in the measurements found using MRI vs. 3D-US. Interclass Correlation Coefficients were used to determine inter- and intra-rater reliability. The mean volume percent difference observed between the two raters for the 3D-US and MRI acquired synovial volumes was 1.77% and 4.76%, respectively. The smallest percent difference in volume found between raters was 0.91% and was from an MR image. A paired sample t-test demonstrated that there was no significant difference between the volumetric values observed between MRI and 3D-US. ICC values of 0.99 and 0.98 for 3D-US and MRI respectively, indicate that there was excellent inter-rater reliability between the two raters. A novel application of a 3D-US acquisition device was evaluated using a CMC OA patient population to determine its clinical feasibility and measurement capabilities in comparison to MRI. As this device is compatible with any commercially available ultrasound machine, it increases its accessibility and ease of use, while proving a method for overcoming some of the limitations associated with radiography, MRI, and 2DUS. 3DUS has the potential to provide clinicians with a tool to quantitatively measure and monitor OA progression at the patient's bedside

The reverse total shoulder replacement (rTSR) has excellent clinical outcomes and prosthesis longevity, and thus, the indications have expanded to a younger age group. The use of a stemless humeral implant has been established in the anatomic TSR; and it is postulated to be safe to use in rTSR, whilst saving humeral bone stock for younger patients. The Lima stemless rTSR is a relatively new implant, with only one paper published on its outcomes. This is a single-surgeon retrospective matched case control study to assess short term outcomes of primary stemless Lima SMR rTSR with 3D planning and Image Derived Instrumentation (IDI), in comparison to a matched case group with a primary stemmed Lima SMR rTSR with 3D planning and IDI. Outcomes assessed: ROM, satisfaction score, PROMs, pain scores; and plain radiographs for loosening, loss of position, notching. Complications will be collated. Patients with at least 1 year of follow-up will be assessed. With comparing the early radiographic and clinical outcomes of the stemless rTSR to a similar patient the standard rTSR, we can assess emerging trends or complications of this new device. 41 pairs of stemless and standard rTSRs have been matched, with 1- and 2-year follow up data. Data is currently being collated. Our hypothesis is that there is no clinical or radiographical difference between the Lima stemless rTSR and the traditional Lima stemmed rTSR

Introduction. At present, orthopaedic surgeons utilize either CT, MRI or X-ray for imaging a joint. Unfortunately, CT and MRI are quite expensive, non weight-bearing and the orthopaedic surgeon does not receive revenue for these procedures. Although x-rays are cheaper, similar to CT scans, patients incur radiation. Also, all three of these imaging modalities are static. More recently, a new ultrasound technology has been developed that will allow a surgeon to image their patients in 3D. The objective of this study is to highlight the new opportunity for orthopaedic surgeons to use 3D ultrasound as alternative to CT, MRI and X-rays. Methods. The 3D reconstruction process utilizes statistical shape atlases in conjunction with the ultrasound RF data to build the patient anatomy in real-time. The ultrasound RF signals are acquired using a linear transducer. Raw RF data is then extracted across each scan line. The transducer is tracked using a 3D tracking system. The location and orientation for each scan line is calculated using the tracking data and known position of the tracker relative to the signal. For each scan line, a detection algorithm extracts the location on the signal of the bone boundary, if any exists. Throughout the scan process, a 3D point cloud is created for each detected bone signal. Using a statistical bone atlas for each anatomy, the patient specific surface is reconstruction by optimizing the geometry to match the point cloud. Missing regions are interpolated from the bone atlas. To validate reconstructed models output models are then compared to models generated from 3D imaging, including CT and MRI. Results. 3D ultrasound, which now has FDA approval in the United States, is presently available for an orthopaedic surgeon to use. Error analyses have been conducted in comparison to MRI and CT scans and revealed that 3D ultrasound has a similar accuracy of less than 1.0 mm in the creation of a 3D bone and soft-tissues. Unlike CT and MRI scans that take in excess of 2–3 weeks to create human bones, 3D ultrasound creates bones in 4–6 minutes. Once the bones are created, the surgeon can assess bone quality, ligament and cartilage conditions, assess osteophytes, fractures and guide needles into the 3D joint space. The creation of 3D bones has been accurately assessed for the spine, shoulder, knee, hip and ankle joints. A 3D joint pre-operative planning module has also been developed for a surgeon to size and position components before surgery. Discussion. 3D ultrasound is an exciting new imaging technology available for orthopaedic surgeons to use in their practice. Existing CPT codes are readily available for 3D ultrasound procedures. A surgeon can now evaluate and diagnose bone and soft- tissue conditions, in 3D, using ultrasound, which is safer and is an easier procedure compared to CT, MRI and X-rays. This new ultrasound technology is a highly accurate imaging technique that will allow a surgeon to diagnose bone and soft-tissue concerns in 3D, under weight-bearing, dynamic conditions and guide needle injections to correct location, in 3D

Abstract. Background. Conventional TKR aims for neutral mechanical alignment which may result in a smaller lateral distal femoral condyle resection than the implant thickness. We aim to explore the mismatch between implant thickness and bone resection using 3D planning software used for Patient Specific Instrumentation (PSI) TKR. Methods. This is a retrospective anatomical study from pre-operative MRI 3D models for PSI TKR. Cartilage mapping allowed us to recreate the native anatomy, enabling us to quantify the mismatch between the distal lateral femoral condyle resection and the implant thickness. Results. We modelled 292 knees from PSI TKR performed between 2012 and 2015. There were 225 varus knees and 67 valgus knees, with mean supine hip-knee-angle of 5.6±3.1 degrees and 3.6±4.6 degrees, respectively. In varus knees, the mean cartilage loss from medial and lateral femoral condyle was 2.3±0.7mm and 1.1±0.8mm respectively; the mean overstuffing of the lateral condyle 1.9±2.2mm. In valgus knees, the mean cartilage loss from medial and lateral condyle was 1.4±0.8mm and 1.5±0.9mm respectively; the mean overstuffing of the lateral condyle was 4.1±1.9mm. Conclusions. Neutral alignment TKR often results in overstuffing of the lateral condyle. This may increase the patello-femoral pressure at the lateral facet in flexion. Anterior knee pain may be persistent even after patellar resurfacing due to tight lateral retinacular structures. An alternative method of alignment such as anatomic alignment may minimise this problem

Joint laxity assessments have been a valuable resource in order to understand the biomechanics and pathologies of the knee. Clinical laxity tests like the Lachman test, Pivot-shift test and Drawer test are, however, subjective of nature and will often only provide basic information of the joint. Stress radiography is another option for assessing knee laxity; however, this method is also limited in terms of quantifiability and one-dimensionality. This study proposes a novel non-invasive low-dose radiation method to accurately measure knee joint laxity in 3D. A method that combines a force controlled parallel manipulator device, a medical image and a biplanar x-ray system. As proof-of-concept, a cadaveric knee was CT scanned and subsequently mounted at 30 degrees of flexion in the device and placed inside a biplanar x-ray scanner. Biplanar x-rays were obtained for eleven static load cases. The preliminary results from this study display that the device is capable of measuring primary knee laxity kinematics similar to what have been reported in previous studies. Additionally, the results also display that the method is capable of capturing coupled motions like internal/external rotation when anteroposterior loads are applied. We have displayed that the presented method is capable of obtaining knee joint laxity in 3D. The method is combining concepts from robotic arthrometry and stress radiography into one unified solution that potentially enables unprecedented 3D joint laxity measurements non-invasively. The method potentially eliminates limitations present in previous methods and significantly reduces the radiation exposure of the patient compared to conventional stress radiography

Anterior shoulder instability is associated with osseous defects of the glenoid and/or humeral head (Hill-Sachs lesions). These defects can contribute to the pathology of instability by engaging together. There is a need to continue to develop methods to preoperatively identify engaging Hill-Sachs lesions for determining appropriate surgical management. The objective was to created a working moveable 3D CT model that allows the user to move the shoulder joint into various positions to assess the relationship between the Hill-Sachs lesion and the anterior glenoid rim. This technique was applied to a cohort series of 14 patients with recurrent anterior dislocation: 4 patients had undergone osteoarticular allografting of Hill-Sachs lesions and 10 control patients had undergone CT scanning to quantify bone loss but had no treatment to address bony pathology. A biomechanical analysis was performed to rotate each 3D model using local coordinate systems through a functional range using an open-source 3D animation program, Blender (Amsterdam, Netherlands). A Hill-Sachs lesion was considered “dynamically” engaging if the angle between the lesion's long axis and anterior glenoid was parallel. In the classical vulnerable position of the shoulder (abduction=90, external rotation=0–135), none of the Hill-Sachs lesions aligned with the anterior glenoid in any of our patients (Figure 1). Therefore, we considered there to be a “low risk” of engagement in these critical positions, as the non-parallel orientation represents a lack of true articular arc mismatch and is unlikely to produce joint instability. We then expanded our search and simulated shoulder positions throughout a physiological range of motion for all groups and found that 100% of the allograft patients and 70% of the controls had positions producing alignment and were “high risk” of engagement (p = 0.18) (Table 1). We also found that the allograft group had a greater number of positions that would engage (mean 4 ± 1 positions of engagement) compared to our controls (mean 2 ± 2 positions of engagement, p = 0.06). We developed a 3D animated paradigm to dynamically and non-invasively visualize a patient's anatomy and determine the clinical significance of a Hill-Sachs lesion using open source software and CT images. The technique demonstrated in this series of patients showed multiple shoulder positions that align the Hill-Sachs and glenoid axes that do not necessarily meet the traditional definition of engagement. Identifying all shoulder positions at risk of “engaging”, in a broader physiological range, may have critical implications towards selecting the appropriate surgical management of bony defects. We do not claim to doubt the classic conceptual definition of engagement, but we merely introduce a technique that accounts for the dynamic component of shoulder motion, and in doing so, avoid limitations of a static criteria assumed traditional definition (like size and location of lesion). Further investigations are planned and will help to further validate the clinical utility of this method. For any figures or tables, please contact the authors directly

Spinal stenosis is a condition resulting in the compression of the neural elements due to narrowing of the spinal canal. Anatomical factors including enlargement of the facet joints, thickening of the ligaments, and bulging or collapse of the intervertebral discs contribute to the compression. Decompression surgery alleviates spinal stenosis through a laminectomy involving the resection of bone and ligament. Spinal decompression surgery requires appropriate planning and variable strategies depending on the specific situation. Given the potential for neural complications, there exist significant barriers to residents and fellows obtaining adequate experience performing spinal decompression in the operating room. Virtual teaching tools exist for learning instrumentation which can enhance the quality of orthopaedic training, building competency and procedural understanding. However, virtual simulation tools are lacking for decompression surgery. The aim of this work was to develop an open-source 3D virtual simulator as a teaching tool to improve orthopaedic training in spinal decompression. A custom step-wise spinal decompression simulator workflow was built using 3D Slicer, an open-source software development platform for medical image visualization and processing. The procedural steps include multimodal patient-specific loading and fusion of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) data, bone threshold-based segmentation, soft tissue segmentation, surgical planning, and a laminectomy and spinal decompression simulation. Fusion of CT and MRI elements was achieved using Fiducial-Based Registration which aligned the scans based on manually placed points allowing for the identification of the relative position of soft and hard tissues. Soft tissue segmentation of the spinal cord, the cerebrospinal fluid, the cauda equina, and the ligamentum flavum was performed using Simple Region Growing Segmentation (with manual adjustment allowed) involving the selection of structures on T1 and/or T2-weighted scans. A high-fidelity 3D model of the bony and soft tissue anatomy was generated with the resulting surgical exposure defined by labeled vertebrae simulating the central surgical incision. Bone and soft tissue resecting tools were developed by customizing manual 3D segmentation tools. Simulating a laminectomy was enabled through bone and ligamentum flavum resection at the site of compression. Elimination of the stenosis enabled decompression of the neural elements simulated by interpolation of the undeformed anatomy above and below the site of compression using Fill Between Slices to reestablish pre-compression neural tissue anatomy. The completed workflow allows patient specific simulation of decompression procedures by staff surgeons, fellows and residents. Qualitatively, good visualization was achieved of merged soft tissue and bony anatomy. Procedural accuracy, the design of resecting tools, and modeling of the impact of bone and ligament removal was found to adequately encompass important challenges in decompression surgery. This software development project has resulted in a well-characterized freely accessible tool for simulating spinal decompression surgery. Future work will integrate and evaluate the simulator within existing orthopaedic resident competency-based curriculum and fellowship training instruction. Best practices for effectively teaching decompression in tight areas of spinal stenosis using virtual simulation will also be investigated in future work

Dynamic 2D sonography of the infant hip is a commonly used clinical procedure for developmental dysplasia of the hip (DDH) screening. It however has been found to be unreliable with some studies reporting associated misdiagnosis rates of up to 29%. In a recent systematic review, Charlton et al. examined dynamic ultrasound (US) screening for hip instability in the first six weeks after birth and found current best practices for such early screening techniques to be divergent between international institutions in terms of clinical scanning protocols. Such protocols include: the appropriate scanning plane and US probe position (e.g. coronal, transverse, lateral, anterior), DDH diagnostic metrics (e.g. femoral head coverage, alpha angle), appropriate patient age when scanning, and follow up procedures. To improve reliability of diagnosis and to help in standardizing diagnosis across different raters and health-centers, we propose an automated method for dynamically assessing hip instability using 3D US. 38 infant hips from 19 patients were scanned with B-mode 3D US by a paediatric orthopaedic surgeon and two technologists from the radiology department at a paediatric tertiary care centre. To quantify hip assessment, we proposed the use of femoral head coverage variability (ΔFHC3D) within 3D US volumes collected during a sequence of US scans (one at rest, and another with posterior stress applied to the joint as maneuvered during a dynamic assessment). We used phase symmetry image features to localize the ilium's vertical cortex and a random forest classifier to identify the location of the femoral head. The proposed ΔFHC3D provided good repeatability with an average test-retest ICC measure of 0.70 (95% confidence interval: 0.35 to 0.87, F(21,21) = 7.738, p<.001). The mean difference of ΔFHC3D measurements was 0.61% with a SD of 4.05%. Since the observed changes in ΔFHC3D start near 0% and range up to about 18% from stable to mildly unstable hips in this cohort, the mean difference and standard deviation of ΔFHC3D measurements observed suggest that the proposed metric and technique likely have sufficient resolution and repeatability to quantify differences in hip laxity. The long-term significance of this approach to evaluating dynamic assessments may lie in increasing early diagnostic accuracy in order to prevent dysplasia remaining undetected prior to manifesting itself in early adulthood joint disease

Objective. Open-wedge high tibial osteotomy (OWHTO) involves performing a corrective osteotomy of the proximal tibia and removing a wedge of bone to correct varus alignment. Although previous studies have investigated changes in leg length before and after OWHTO using X-rays, none has evaluated three-dimensional (3D) leg length changes after OWHTO. We therefore used 3D preoperative planning software to evaluate changes in leg length after OWHTO in three dimensions. Methods. The study subjects were 55 knees of 46 patients (10 men and 36 women of mean age 69.9 years) with medial osteoarthritis of the knee or osteonecrosis of the medial femoral condyle with a femorotibial angle of >185º and restricted range of motion (extension <–10º, flexion <130º), excluding those also suffering from patellofemoral arthritis or lateral osteoarthritis of the knee. OWHTO was simulated from computed tomography scans of the whole leg using ZedHTO 3D preoperative planning software. We analyzed the hip-knee-ankle angle (HKA), flexion contracture angle (FCA), mechanical medial proximal tibial angle (mMPTA), angle of correction, wedge length, 3D tibial length, 3D leg length, and 3D increase in leg length before and after OWHTO. We also performed univariate and multivariate analysis of factors affecting the change in leg length (preoperative and postoperative H-K-A angle, wedge length, and correction angle). Results. Mean HKA increased significantly from −4.7º ± 2.7º to 3.5º ± 1.3º, as did mean mMPTA from 83.7º ± 3.3º to 92.5º ± 3.0º (p <0.01). Mean FCA was 4.7º ± 3.6° preoperatively and 4.8º ± 3.3º postoperatively, a difference that was not significant (p = 0.725). The mean correction angle was 9.1º ± 2.8º and the mean wedge length was 9.4º ± 3.2º mm. Mean tibial length increased significantly by 4.7 ± 2.3 mm (p <0.01), and mean leg length by 5.6 ± 2.8 mm (p <0.01). The change in leg length was strongly correlated with wedge length (R = 0.846, adjusted R. 2. = 0.711, p <0.01). Discussion and Conclusion. Mean 3D leg length after OWHTO increased significantly by 5.4 ± 3.1 mm. A difference in leg length of >5 mm is believed to affect back pain and gait abnormalities, and changes in leg length must therefore be taken into consideration. The 3D dimensional change in leg length was strongly correlated with wedge length, and could be predicted by the formula (change in leg length in mm) = [(wedge length in mm) ×0.75) − 1.5]. For any figures or tables, please contact authors directly

Introduction. Although weight-bearing CT of the foot definitely reflects the morphology and deformity of joint, it is hard to obtain the standing CT due to difficulty of availability. Although 3D imaging reconstruction using radiographs has been reported in other joints, there is no study about foot joint. The purpose of this study is to develop a semi-automatic method based on a deformable surface fitting for achieving the weight-bearing 3D model reconstruction from standing radiographs for foot. Methods. Our method is based on a Laplacian surface deformation framework using a template model of foot. As pre- processing step, we obtained template surface meshes having the average shapes of foot bones (talus, calcaneus) from standing CT images (Planmed Verity) in 10 normal volunteers. In the reconstruction step, the surface meshes are deformed following guided user inputs with geometric constraints to recover the target shapes of 30 patients while preserving average bone shape and smoothness. Finally, we compared reconstructed 3D model to original standing CT images. Analysis was performed using Dice coefficients, average shape distance, maximal shape distance. Results. The obtained reconstruction model is close to the actual standing foot geometry (Dice coefficients 0.89, average shape distance 0.88 mm, maximum shape distance 6.33 mm). We present the accuracy and robustness of our method via comparison between the reconstructed 3D models and the original bone surfaces. Conclusions. Weight-bearing 3D foot model reconstruction from standing radiographs is concise and the effective method for analysis of foot joint alignment and deformity

Introduction. Finite element (FE) models are commonly used to analyse the mechanical behaviour of the bone under different conditions. They provide detail information but they can be numerically expensive and this limits their use in cases where large or numerous simulations are required. On the other hand, 2D models show less computational cost but the precision of results depends on the approach used for the simplification. Three 2D approaches are commonly used: models without side-plate (WOSP)[1]; models with variable thickness side-plate and constant cortical thickness (SPCT)[2]; models with side-plate and variable cortical thickness (SPVT)[3]. The aim of this study is to determine which 2D approach reproduces best the FE results obtained with a 3D model involving hip stems. Methods. The 2D models were generated by the intersection of the 3D model with the stem symmetry plane. Three approaches were considered to assure 3D-2D correspondence: 1) consider variable thickness for the cortical elements so that their transversal area moment of inertia equals the cross-sectional area moment of inertia from the 3D model (model WOSP); 2) include an additional side-plate with variable thickness to match the area moment of inertia from the 3D model, and consider constant thickness for the cortical bone elements (model SPCT); 3) include the side-plate but consider variable thickness for the cortical bone elements, derived from the 3D model (model SPVT). In all cases, the cancellous bone and stem elements had variable thickness computed so that their transversal area moment of inertia was equal to the cross-sectional area moment of inertia measured in the 3D model. This was done at different levels (Fig.1), providing a thickness distribution for the 2D elements. FE analyses were carried out for the static loading condition simulating stair climbing[4]. All materials were defined as linear isotropic and homogeneous. The post-operative situation where bone ingrowth is achieved was considered, resulting in bonded contact between the bone and the implant. The comparison between the 2D and 3D models was done based on three physical quantities: the Von Mises stresses (σ. VM. ); the strain energy density (U) and the interfacial shear stress (t) along the stem-bone interface. Results. Fig.2 shows the σ. VM. , U and t distributions for the 3D model and in the three 2D models. In general, the values for the three physical quantities were under estimated in all 2D models although the differences were small. However, the maximum values of σ. VM. and U were larger in the 2D models than in the 3D model, whereas maximum t values were under estimated. Discussion. It is possible to use 2D simplifications based on the stem symmetry plane to perform FE analyses when large number of simulations is needed or when the computational cost needs to be limited. In this way, a side-plate with variable thickness should be considered to obtain close results to the 3D model, while cortical bone thickness can be kept constant and cancellous bone thickness is varied. For figures/tables, please contact authors directly.

Good clinical outcomes of Total Knee Arthroplasty (TKA) demand the ability to plan a surgery precisely and measure the outcome accurately. In comparison with plain radiograph, CT-based 3D planning offers several advantages. More specifically, CT has the benefits of avoiding errors resulting from magnification and inaccurate patient positioning. Additional benefits include the assessment in the axial plane and the replacement of 2D projections with 3D data. The concern on 3D CT-based planning, however, lies in the increase of radiation dosage to the patients. An alternative is to reconstruct a patient-specific 3D model of the complete lower extremity from 2D X-ray radiographs. This study presents a clinical validation of a novel technology called “3XPlan” which allows for 3D prosthesis planning using 2D X-ray radiographs. After a local institution review board (IRB) approval, 3XPlan was evaluated on 24 patients TKA. Pre-operatively, all the patients underwent a CT scan according to a standard protocol. Image acquisition consisted of three separate short spiral axial scans: 1) ipsilateral hip, 2) affected knee and 3) ipsilateral ankle. All the CT images were segmented to extract 3D surface models of both femur and tibia, which were regarded as the ground truth. Additionally, 2 X-ray images were acquired for each affected leg and were used in 3XPlan to derive patient-specific models of the leg. For 3D models derived from both modalities (CT vs. X-ray), five most relevant anatomical parameters for planning TKA were measured and compared with each other. Except for tibial torsion, the average differences for all other anatomical parameters are smaller than or close to 3 degrees

Purpose. To achieve 3D kinematic analysis of total knee arthroplasty (TKA), 2D/3D registration techniques, which use X-ray fluoroscopic images and computer aided design model of the knee implants, have been applied to clinical cases. However, most conventional methods have needed time-consuming and labor-intensive manual operations in some process. In particular, for the 3D pose estimation of tibial component model from X-ray images, these manual operations were carefully performed because the pose estimation of symmetrical tibial component get severe local minima rather than that of unsymmetrical femoral component. In this study, therefore, we propose an automated 3D kinematic estimation method of tibial component based on statistical motion model, which is created from previous analyzed 3D kinematic data of TKA. Methods. The used 2D/3D registration technique is based on a robust feature-based (contour-based) algorithm. In our proposed method, a statistical motion model which represents average and variability of joint motion is incorporated into the robust feature-based algorithm, particularly for the pose estimation of tibial component. The statistical motion model is created from previous a lot of analyzed 3D kinematic data of TKA. In this study, a statistical motion model for relative knee motion of the tibial component with respect to the femoral component was created and utilized. Fig. 1 shows each relative knee motion model for six degree of freedom (three translations and three rotations parameter). Thus, after the pose estimation of the femoral component model, 3D pose of the tibial component model is determined by maximum a posteriori (MAP) estimation using the new cost function introduced the statistical motion model. Experimental results. To validate the feasibility and effectiveness of 3D pose estimation for the tibial component using the proposed method, experiments using X-ray fluoroscopic images of 20 TKA patients under the squatting knee motion were performed. For the creation of correct pose (reference data) and the statistical motion model, we used the 3D pose data which were got by carefully applying previous method to the contour images which spurious edges and noises were removed manually. In order to ensure the validity for the statistical motion model of the proposed method, leave-one-out cross validation method was applied. In the 3D pose estimation of tibial component model, for the only first frame, initial guess pose of the model was manually given. For all images except for the first frame, the 3D pose of the model was automatically estimated without manual initial guess pose of the model. To assess the automation performance, the automation rate was calculated, and the rate was defined as the X-ray frame number of satisfying clinical required accuracy (error within 1mm, 1 degree) relative to all X-ray frame number. As results of the experiments, 3D pose of the tibial component model for all X-ray images except for the first frame was full-automatically stably-estimated, and the automation rate was 80.1 %. Conclusions. The proposed method by MAP estimation introduced the statistical motion model was successfully performed, and did not need labor-intensive manual operations for 3D pose estimation of tibial component. For any figures or tables, please contact authors directly (see Info & Metrics tab above).