Computer-assisted solutions are changing surgical practice continuously. One of the most disruptive technologies among the computer-integrated surgical techniques is Augmented Reality (AR). While ...Augmented Reality is increasingly used in several medical specialties, its potential benefit in orthopedic surgery is not yet clear. The purpose of this article is to provide a systematic review of the current state of knowledge and the applicability of AR in orthopedic surgery.
A systematic review of the current literature was performed to find the state of knowledge and applicability of AR in Orthopedic surgery. A systematic search of the following three databases was performed: "PubMed", "Cochrane Library" and "Web of Science". The systematic review followed the Preferred Reporting Items on Systematic Reviews and Meta-analysis (PRISMA) guidelines and it has been published and registered in the international prospective register of systematic reviews (PROSPERO).
31 studies and reports are included and classified into the following categories: Instrument / Implant Placement, Osteotomies, Tumor Surgery, Trauma, and Surgical Training and Education. Quality assessment could be performed in 18 studies. Among the clinical studies, there were six case series with an average score of 90% and one case report, which scored 81% according to the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC). The 11 cadaveric studies scored 81% according to the QUACS scale (Quality Appraisal for Cadaveric Studies).
This manuscript provides 1) a summary of the current state of knowledge and research of Augmented Reality in orthopedic surgery presented in the literature, and 2) a discussion by the authors presenting the key remarks required for seamless integration of Augmented Reality in the future surgical practice.
PROSPERO registration number: CRD42019128569.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background:
Increased external tibial torsion and tibial tuberosity–trochlear groove distance (TTTG) affect patellofemoral instability and can be corrected by tibial rotational osteotomy and tibial ...tuberosity transfer. Thus far, less attention has been paid to the combined correction of tibial torsion and TTTG by supratuberositary osteotomy.
Purpose:
To quantify the effect of a supratuberositary torsional osteotomy on TTTG.
Study Design:
Descriptive laboratory study.
Methods:
Seven patients who underwent supratuberositary osteotomy to treat patellofemoral instability and an additional 13 patients with increased TTTG were included (N = 20). With 3-dimensional (3D) surface models, supratuberositary rotational osteotomies were simulated with predefined degrees of rotation. Concomitant 3D TTTG was measured by a novel and validated measurement method. In addition, all operated patients underwent 2-dimensional (2D) radiographic evaluation with pre- and postoperative computed tomography data. Absolute differences among simulated, predicted, and achieved postoperative corrections were compared.
Results:
A total of 500 supratuberositary osteotomies were simulated. The linear regression estimate yielded a change of −0.68 mm (95% CI, −0.72 to −0.63; P < .0001) in 3D TTTG per degree of tibial rotation, and 2D and 3D TTTG measurements in the operated patients were comparable in pre- and postoperative measurements (preoperative, 19.8 ± 2.5 mm and 20.0 ± 2.4 mm; postoperative, 13.6 ± 3.8 mm and 14.6 ± 3.4 mm, respectively). Postoperative 2D TTTG deviated in absolute terms from predicted (regression) and simulated TTTG by 1.4 ± 1.0 mm and 1.5 ± 0.6 mm. Inter- and intrarater reliability (intraclass correlation coefficient) for radiological and simulated measurements ranged between 0.883 and 0.996 and were almost perfect.
Conclusion:
In supratuberositary osteotomy, TTTG changes by −0.68 mm per degree of internal tibial rotation. The absolute mean difference between postoperative predicted TTTG and 2D TTTG was only 1.4 mm. Thus, TTTG correction can be successfully predicted by the degree of tibial rotation.
Clinical Relevance:
TTTG correction can be successfully predicted by the degree of tibial rotation. Therefore, in selected cases, tibial torsional deformity and TTTG can be corrected by 1 osteotomy. However, isolated rotations have been performed, and unintended translational movements during tibial rotation may alter the postoperative results.
Purpose
High tibial osteotomy (HTO) is an effective treatment option in early osteoarthritis. However, preoperative planning and surgical execution can be challenging. Computer assisted ...three-dimensional (3D) planning and patient-specific instruments (PSI) might be helpful tools in achieving successful outcomes. Goal of this study was to assess the accuracy of HTO using PSI.
Methods
All medial open wedge PSI-HTO between 2014 and 2016 were reviewed. Using pre- and postoperative radiographs, hip-knee-ankle angle (HKA) and posterior tibial slope (PTS) were determined two-dimensionally (2D) to calculate 2D accuracy. Using postoperative CT-data, 3D surface models of the tibias were reconstructed and superimposed with the planning to calculate 3D accuracy.
Results
Twenty-three patients could be included. A mean correction of HKA of 9.7° ± 2.6° was planned. Postoperative assessment of HKA correction showed a mean correction of 8.9° ± 3.2°, resulting in a 2D accuracy for HKA correction of 0.8° ± 1.5°. The postoperative PTS changed by 1.7° ± 2.2°. 3D accuracy showed average 3D rotational differences of − 0.1° ± 2.3° in coronal plane, − 0.2° ± 2.3° in transversal plane, and 1.3° ± 2.1° in sagittal plane, whereby 3D translational differences were calculated as 0.1 mm ± 1.3 mm in coronal plane, − 0.1 ± 0.6 mm in transversal plane, and − 0.1 ± 0.6 mm in sagittal plane.
Conclusion
The use of PSI in HTO results in accurate correction of mechanical leg axis. In contrast to the known problem of unintended PTS changes in conventional HTO, just slight changes of PTS could be observed using PSI. The use of PSI in HTO might be preferable to obtain desired correction of HKA and to maintain PTS.
Purpose
Joint line orientation (JLO) plays an important role in total knee arthroplasty (TKA), but its influence on patient-reported outcomes (PROs) is unclear. The purpose of this study was to ...examine JLO impact as measured by the forgotten joint score (FJS-12). The hypothesis was that restoring the joint line (JL) parallel to the floor would influence joint awareness favorably, i.e., allow the patient to forget about the joint in daily living.
Methods
All computer-navigated primary TKAs using a cemented, cruciate-retaining (CR) design implanted between January 2018 and September 2019 were reviewed in this retrospective single-center analysis. Primary endpoints were: clinical range of motion (ROM), and patient-reported (FJS-12) and radiographical outcomes tibia joint line angle (TJLA), hip knee axis (HKA), mechanical medial proximal tibia angle (mMPTA) as well as mechanical lateral distal femoral angle (mLDFA).
Results
Seventy-six patients (mean age: 70.3 ± 9.7 years, mean BMI: 29.7 ± 5.2 kg/m
2
) were included. Postoperative ROM averaged 118.7 ± 9.6°. The mean FJS-12 improved from 16.4 ± 15.3 (preoperatively) to 89.4 ± 16.9 (1-year follow-up;
p
< 0.001). Clinical outcomes and PROs did not correlate with JLO (
p
= n.s.). Cluster analysis using six measures revealed that a medially opened TJLA was associated with significantly better postoperative FJS-12.
Conclusion
Tibial JLO was found to have no effect on PROs. Considering the JLO in the coronal plane alone probably has questionable clinical relevance. Lower limb alignment should be assessed in all three planes and correlated with the clinical outcome.
Level of clinical evidence
Level IV.
Purpose
Patient-specific instruments (PSIs) are helpful tools in high tibial osteotomy (HTO) in patients with symptomatic varus malalignment of the mechanical leg axis. However, the precision of HTO ...can decrease with malpositioned PSI. This study investigates the influence of malpositioned PSI on axis correction, osteotomy, and implant placement.
Methods
With a mean three-dimensional (3D) model (0.8° varus), PSI-navigated HTOs were computer simulated. Two different guide designs, one with stabilising hooks and one without, were used. By adding rotational and translational offsets of different degrees, wrong placements of PSI were simulated. After 5° valgisation of the postoperative mechanical axis, the distance between joint-plane and osteotomy screws, respectively, were measured. The same simulations were performed in a patient with varus deformity (7.4° varus).
Results
In the mean 3D model, the postoperative mechanical axis was within 3.9°–4.5° valgus with mean value of 4.1° ± 0.1° (correct axis 4.2° valgus). Surgical failure concerning osteotomy occurred in 17 of 76 HTOs. Significantly safer screw placement was observed using PSI with stabilising hooks (
p
= 0.012). In the case of the 3D model with 7.4° varus deformity, the postoperative mechanical axis was within 3.2°–3.9° valgus with mean value of 3.8° ± 0.2° (correct axis 3.9° valgus). Surgical failure concerning osteotomy occurred in 3 of 38 HTOs. Screws were always within the safety distance.
Conclusion
The clinical relevance of the presented study is that malpositioning of a PSI within the possible degrees of freedom does not have a relevant influence on the axis correction. The most vulnerable plane for surgical failure is the sagittal plane, wherefore the treating surgeon should verify correct guide placement to prevent surgical failure, particularly in this plane.
Level of evidence
III.
Deformity assessment and preoperative planning of realignment surgery are conventionally based on weight-bearing (WB) radiographs. However, newer technologies such as three-dimensional (3D) ...preoperative planning and surgical navigation with patient-specific instruments (PSI) rely on non-weight bearing (NWB) computed tomography (CT) data. Additionally, differences between conventional two-dimensional (2D) and 3D measurements are known. The goal of the present study was to systematically analyse the influence of WB and the measurement modality (2D versus 3D) on common WB-dependent measurements used for deformity assessment.
85 lower limbs could be included. Two readers measured the hip-knee-ankle angle (HKA) and the joint line convergence angle (JLCA) in 2D WB and 2D NWB radiographs, as well as in CT-reconstructed 3D models using an already established 3D measurement method for HKA, and a newly developed 3D measurement method for JLCA, respectively. Interrater and intermodality reliability was assessed.
Significant differences between WB and NWB measurements were found for HKA (p < 0.001) and JLCA (p < 0.001). No significant difference could be observed between 2D HKA NWB and 3D HKA (p = 0.09). The difference between 2D JLCA NWB and 3D JLCA was significant (p < 0.001). The intraclass correlation coefficient (ICC) for the interrater agreement was almost perfect for all HKA and 3D JLCA measurements and substantial for 2D JLCA WB and 2D JLCA NWB. ICC for the intermodality agreement was almost perfect between 2D HKA WB and 2D HKA NWB as well as between 2D HKA NWB and 3D HKA, whereas it was moderate between 2D JLCA WB and 2D JLCA NWB and between 2D JLCA NWB and 3D JLCA.
Limb loading results in significant differences for both HKA and JLCA measurements. Furthermore, 2D projections were found to be insufficient to represent 3D joint anatomy in complex cases. With an increasing number of surgical approaches based on NWB CT-reconstructed models, research should focus on the development of 3D planning methods that consider the effects of WB on leg alignment.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Corrective osteotomies for complex proximal femoral deformities can be challenging; wherefore, subsidies in preoperative planning and during surgical procedures are considered helpful. ...Three-dimensional (3D) planning and patient-specific instruments (PSI) are already established in different orthopedic procedures. This study gives an overview on this technique at the proximal femur and proposes a new indirect reduction technique using an angle blade plate.
Using computed tomography (CT) data, 3D models are generated serving for the preoperative 3D planning. Different guides are used for registration of the planning to the intraoperative situation and to perform the desired osteotomies with the following reduction task. A new valuable tool to perform the correction is the use of a combined osteotomy and implant-positioning guide, with indirect deformity reduction over an angle blade plate.
An overview of the advantages of 3D planning and the use of PSI in complex corrective osteotomies at the proximal femur is provided. Furthermore, a new technique with indirect deformity reduction over an angle blade plate is introduced.
Using 3D planning and PSI for complex corrective osteotomies at the proximal femur can be a useful tool in understanding the individual deformity and performing the aimed deformity reduction. The indirect reduction over the implant is a simple and valuable tool in achieving the desired correction, and concurrently, surgical exposure can be limited to a subvastus approach.
Abstract
Background
Several hip and knee pathologies are associated with aberrant femoral torsion. Diagnostic workup includes computed tomography (CT) and magnetic resonance imaging (MRI). For ...three-dimensional (3D) analysis of complex deformities it would be desirable to measure femoral torsion from MRI data to avoid ionizing radiation of CT in a young patient population. 3D measurement of femoral torsion from MRI has not yet been compared to measurements from CT images. We hypothesize that agreement will exist between MRI and CT 3D measurements of femoral torsion.
Methods
CT and MRI data from 29 hips of 15 patients with routine diagnostic workup for suspected femoroacetabular impingement (FAI) were used to generate 3D bone models. 3D measurement of femoral torsion was performed by two independent readers using the method of Kim et al. which is validated for CT. Inter-modalitiy and inter-reader intraclass correlation coefficients (ICC) were calculated.
Results
Between MRI and CT 3D measurements an ICC of 0.950 (0.898; 0.976) (reader 1) respectively 0.950 (0.897; 0.976) (Reader 2) was found. The ICC (95% CI) expressing the inter-reader reliability for both modalities was 0.945 (0.886; 0.973) for MRI and 0.957 (0.910; 0.979) for CT, respectively. Mean difference between CT and MRI measurement was 0.42° (MRI – CT, SD: 2.77°,
p
= 0.253).
Conclusions
There was consistency between 3D measurements of femoral torsion between computer rendered MRI images compared to measurements with the “gold standard” of CT images. ICC for inter-modality and inter-reader consistency indicate excellent reliability. Accurate, reliable and reproducible 3D measurement of femoral torsion is possible from MRI images.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The tibial slope plays an important role in knee surgery. However, standard radiographic measurement techniques have a low reproducibility and do not allow differentiation between medial and lateral ...articular surfaces. Despite availability of three-dimensional imaging, so far, no real 3D measurement technique was introduced and compared to radiographic measurement, which were the purposes of this study.
Computed tomography scans of 54 knees in 51 patients (41 males and 10 females) with a mean age of 46 years (range 22-67 years) were included. A novel 3D measurement technique was applied by two readers to measure the tibial slope of medial and lateral tibial plateau and rim. A statistical analysis was conducted to determine the intraclass correlation coefficient (ICC) for the new technique and compare it to a standard radiographic measurement.
The mean 3D tibial slope for the medial plateau and rim was 7.4° and 7.6°, for the lateral plateau and rim 7.5° and 8.1°, respectively. The mean radiographic slope was 6.0°. Statistical analysis showed an ICC between both readers of 0.909, 0.987, 0.918, 0.893, for the 3D measurement of medial plateau, medial rim, lateral plateau and lateral rim, respectively, whereas the radiographic technique showed an ICC of 0.733.
The proposed novel measurement technique shows a high intraclass agreement and offers an applicable opportunity to assess the tibial slope three-dimensionally. Furthermore, the medial and lateral articular surfaces can be measured separately and one can differentiate the slope from the plateau and from the rim. As three-dimensional planning becomes successively more important, our measurement technique might deliver a useful supplement to the standard radiographic assessment in slope related knee surgery.
Level III, diagnostic study.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Subtrochanteric or supracondylar femoral rotational osteotomies are established surgical treatments for femoral rotational deformities. Unintended change of the mechanical leg axis is an identified ...problem. Different attempts exist to plan a correct osteotomy plane, but implementation of the preoperative planning into the surgical situation can be challenging. Goal of this study was to identify the critical threshold of mal-angulation of the osteotomy plane and of femoral rotation that leads to a relevant deviation of the postoperative mechanical leg axis using a computer simulation approach.
Three-dimensional (3D) surface models of the lower extremity of two patients (Model 1: 42° femoral antetorsion; Model 2: 6° femoral retrotorsion) were generated from computed tomography data. First, baseline subtrochanteric and supracondylar rotational osteotomies, perpendicular to the femoral mechanical axis were simulated. Afterwards, mal-angulated osteotomies in sagittal and frontal plane followed by different degrees of rotation were simulated and frontal mechanical axis was analyzed.
400 mal-angulated osteotomies have been simulated. Mal-angulation of ±30° with 30° rotation showed maximum deviation from preoperative mechanical axis in subtrochanteric osteotomies (4.0° ± 0.4°) and in supracondylar osteotomies (12.4° ± 0.8°). Minimal mal-angulation of 15° in sagittal plane in subtrochanteric osteotomies and mal-angulation of 10° in sagittal plane in supracondylar osteotomies altered the mechanical axis by > 2°. Mal-angulation in sagittal plane showed higher deviations of the mechanical axis (up to 12.4° ± 0.8°), than in frontal plane mal-angulation (up to 4.0° ± 1.9°).
A femoral rotational osteotomy, perpendicular to the femoral mechanical axis, has no considerable influence on the mechanical leg axis. However, mal-angulation of femoral rotational osteotomies showed relevant changes of the mechanical leg axis. In supracondylar respectively subtrochanteric procedures, mal-angulation of only 10° in combination with already 15° of femoral rotation respectively mal-angulation of 15° in combination with 30° of femoral rotation, can lead to a relevant postoperative mechanical leg axis deviation of more than 2°, wherefore these patients probably would benefit from the use of navigation aids.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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