Reverse total shoulder arthroplasty (RTSA) has been reported to be associated with a complication rate that is four times that of conventional total shoulder arthroplasty. It is the purpose of this ...article to identify and understand the most common and most serious complications of RTSA and to review current methods of prevention and treatment. The current literature was reviewed to identify type and prevalence of reported complications and to identify risk factors, preventive measures as well as technical details for management strategies for complications of RTSA. The variable accuracy of reporting and the heterogeneity of methodology in the literature limited our study, however, a definitive ranking of most to least common complication emerged. The currently identified most common complication is scapular notching. The clinically most relevant complications are infection, instability and acromial fractures. Haematoma formation used to be very frequent but can be controlled, glenoid component loosening, however, is rare when compared with conventional total shoulder replacement. In conclusion, RTSA is associated with a high rate of complications. Their incidence and the results of their treatment are inconsistently reported. To document and then prevent complications, a standardised monitoring tool including clear definitions and assessment instructions appears necessary.
Purpose
To evaluate whether 3D-printed vertebrae offer realistic haptic simulation of posterior pedicle screw placement and decompression surgery with normal to osteoporotic-like properties.
Methods
...A parameterizable vertebra model was developed, adjustable in cortical and cancellous bone thicknesses. Based on this model, five different L3 vertebra types (α, β, γ1, γ2, and γ3) were designed and fourfold 3D-printed. Four spine surgeons assessed each vertebra type and a purchasable L3 Sawbones vertebra. Haptic behavior of six common steps in posterior spine surgery was rated from 1 to 10: 1–2: too soft, 3–4: osteoporotic, 5–6: normal, 7–8: hard, and 9–10: too hard. Torques were measured during pedicle screw insertion.
Results
In total, 24 vertebrae (six vertebra types times four examiners) were evaluated. Mean surgical assessment scores were: α 3.2 ± 0.9 (osteoporotic), β 1.9 ± 0.7 (too soft), γ1 4.7 ± 0.9 (osteoporotic–normal), γ2 6.3 ± 1.1 (normal), and γ3 7.5 ± 1.1 (hard). All surgeons considered the 3D-printed vertebrae α, γ1, and γ2 as more realistic than Sawbones vertebrae, which were rated with a mean score of 4.1 ± 1.7 (osteoporotic–normal). Mean pedicle screw insertion torques (Ncm) were: α 32 ± 4, β 12 ± 3, γ1 74 ± 4, γ2 129 ± 13, γ3 196 ± 34 and Sawbones 90 ± 11.
Conclusions
In this pilot study, 3D-printed vertebrae displayed haptically and biomechanically realistic simulation of posterior spinal procedures and outperformed Sawbones. This approach enables surgical training on bone density-specific vertebrae and provides an outlook toward future preoperative simulation on patient-specific spine replicas.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
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.
Knowledge of spinal kinematics is essential for the diagnosis and management of spinal diseases. Distinguishing between physiological and pathological motion patterns can help diagnose these ...diseases, plan surgical interventions and improve relevant tools and software. During the last decades, numerous studies based on diverse methodologies attempted to elucidate spinal mobility in different planes of motion. The authors aimed to summarize and compare the evidence about cervical spine kinematics under healthy and degenerative conditions. This includes an illustrated description of the spectrum of physiological cervical spine kinematics, followed by a comparable presentation of kinematics of the degenerative cervical spine. Data was obtained through a systematic MEDLINE search including studies on angular/translational segmental motion contribution, range of motion, coupling and center of rotation. As far as the degenerative conditions are concerned, kinematic data regarding disc degeneration and spondylolisthesis were available. Although the majority of the studies identified repeating motion patterns for most motion planes, discrepancies associated with limited sample sizes and different imaging techniques and/or spine configurations, were noted. Among healthy/asymptomatic individuals, flexion extension (FE) and lateral bending (LB) are mainly facilitated by the subaxial cervical spine. C4–C5 and C5–C6 were the major FE contributors in the reported studies, exceeding the motion contribution of sub-adjacent segments. Axial rotation (AR) greatly depends on C1–C2. FE range of motion (ROM) is distributed between the atlantoaxial and subaxial segments, while AR ROM stems mainly from the former and LB ROM from the latter. In coupled motion rotation is quantitatively predominant over translation. Motion migrates caudally from C1–C2 and the center of rotation (COR) translocates anteriorly and superiorly for each successive subaxial segment. In degenerative settings, concurrent or subsequent lesions render the association between diseases and mobility alterations challenging. The affected segments seem to maintain translational and angular motion in early and moderate degeneration. However, the progression of degeneration restrains mobility, which seems to be maintained or compensated by adjacent non-affected segments. While the kinematics of the healthy cervical spine have been addressed by multiple studies, the entire nosological and kinematic spectrum of cervical spine degeneration is partially addressed. Large—scale
in vivo
studies can complement the existing evidence, cover the gaps and pave the way to technological and clinical breakthroughs.
In this work, we developed and validated a computer method capable of robustly detecting drill breakthrough events and show the potential of deep learning-based acoustic sensing for surgical error ...prevention. Bone drilling is an essential part of orthopedic surgery and has a high risk of injuring vital structures when over-drilling into adjacent soft tissue. We acquired a dataset consisting of structure-borne audio recordings of drill breakthrough sequences with custom piezo contact microphones in an experimental setup using six human cadaveric hip specimens. In the following step, we developed a deep learning-based method for the automated detection of drill breakthrough events in a fast and accurate fashion. We evaluated the proposed network regarding breakthrough detection sensitivity and latency. The best performing variant yields a sensitivity of Formula: see text% for drill breakthrough detection in a total execution time of 139.29Formula: see text. The validation and performance evaluation of our solution demonstrates promising results for surgical error prevention by automated acoustic-based drill breakthrough detection in a realistic experiment while being multiple times faster than a surgeon's reaction time. Furthermore, our proposed method represents an important step for the translation of acoustic-based breakthrough detection towards surgical use.
Purpose
Dorsal spinal instrumentation with pedicle screw constructs is considered the gold standard for numerous spinal pathologies. Screw misplacement is biomechanically disadvantageous and may ...create severe complications. The aim of this study was to assess the accuracy of patient-specific template-guided pedicle screw placement in the thoracic and lumbar spine compared to the free-hand technique with fluoroscopy.
Methods
Patient-specific targeting guides were used for pedicle screw placement from Th2–L5 in three cadaveric specimens by three surgeons with different experience levels. Instrumentation for each side and level was randomized (template-guided vs. free-hand). Accuracy was assessed by computed tomography (CT), considering perforations of <2 mm as acceptable (safe zone). Time efficiency, radiation exposure and dependencies on surgical experience were compared between the two techniques.
Results
96 screws were inserted with an equal distribution of 48 screws (50 %) in each group. 58 % (
n
= 28) of template-guided (without fluoroscopy) vs. 44 % (
n
= 21) of free-hand screws (with fluoroscopy) were fully contained within the pedicle (
p
= 0.153). 97.9 % (
n
= 47) of template-guided vs. 81.3 % (
n
= 39) of free-hand screws were within the 2 mm safe zone (
p
= 0.008). The mean time for instrumentation per level was 01:14 ± 00:37 for the template-guided vs. 01:40 ± 00:59 min for the free-hand technique (
p
= 0.013), respectively. Increased radiation exposure was highly associated with lesser experience of the surgeon with the free-hand technique.
Conclusions
In a cadaver model, template-guided pedicle screw placement is faster considering intraoperative instrumentation time, has a higher accuracy particularly in the thoracic spine and creates less intraoperative radiation exposure compared to the free-hand technique.
Objectives
The aim of this study was to apply texture analysis (TA) on paraspinal musculature in T2-weighted (T2w) magnetic resonance images (MRI) of symptomatic lumbar spinal stenosis (LSS) patients ...and correlate the findings with clinical outcome measures.
Methods
Ninety patients were prospectively enrolled in the multi-centric Lumbar Stenosis Outcome Study (LSOS). All patients received a T2w MRI, from which we selected axial images perpendicular to the intervertebral disc at level L3/4 for TA. Regions-of-interest (ROI) were drawn of the paraspinal musculature and 304 TA features/ ROI were calculated. As clinical outcome measurements, we analysed three commonly applied measures: Spinal Stenosis Measure (SSM), Roland-Morris Disability Questionnaire (RMDQ), as well as the Numeric Rating Scale (NRS). We used two machine learning-based classifiers: Decision table, and k-nearest neighbours (k-NN).
Results
We observed no meaningful correlation between TA in paraspinal musculature and the two clinical outcome measures SSM symptoms and SSM function, while a moderate correlation was observed regarding the outcome measures RMDQ (k-NN: r = 0.56) and NRS (Decision Table: r = 0.72).
Conclusions
In conclusion, MR TA is a viable tool to quantify medical images and illustrate correlations of microarchitectural changes invisible to a human reader with potential clinical impact.
Key Points
• TA is feasible on paraspinal musculature using MRI.
• TA on paraspinal musculature correlates with SSM and RMDQ.
• TA may enable a statement regarding clinical impact of imaging findings.
Abstract
Surgical site infection (SSI) may cause a substantial burden for patients and healthcare systems. A potential risk of different architectures of the operating room for SSI is yet unknown and ...was subject of this study. This observational cohort study was performed in a university hospital and evaluated patients, who underwent a broad spectrum of orthopedic surgeries in 2016 (open-plan operating room architecture) versus (vs) 2017 (closed-plan operating room architecture). Patients, who underwent surgery in the transition time period from the open-plan to the closed-plan operating room architecture and those, who were treated e.g. for osteomyelitis as index procedure were excluded. The primary outcome was revision surgery for early SSI within 30 (superficial) or 90 (deep or organ/space) days of surgery. Age, gender, American society of anesthesiologists (ASA) classification, and the body mass index (BMI) were considered as potential interacting factors in a logistic regression analysis. The incidence of revisions for SSI was 0.6 percent (%) (n = 45) in the 7'740 included surgical cases (mean age of 52 (standard deviation (SD) 19) years; n = 3'835 (50%) females). There was no difference in incidences of revision for SSI in the open- vs closed-plan operating room architecture (0.5% vs 0.7%; adjusted odds ratio (OR) = 1.34 (95% confidence interval (CI) 0.72–2.49,
P
= 0.35)). Age and gender were not a risk factor for revision for SSI. However, ASA classification and BMI were identified as risk factors for the incidence of revision for SSI (OR = 1.92 (95% CI 1.16- 3.18,
P
= 0.01) and OR = 1.05 (95% CI 1.00–1.11,
P
= 0.05)). The overall incidence of revisions for early SSI after a broad spectrum of orthopedic surgeries was relatively low (0.6%) and independent from the operating room architecture. An increase in ASA classification and possibly BMI, however, were identified as independent risk factors for revision for SSI.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in postoperative pain management. While an increasing number of in vitro and animal studies point toward an inhibitory effect of NSAIDs ...on bone healing process, the few existing retro- and prospective clinical studies present conflicting data.
The aim of this qualitative, systematic review was to investigate the impact of perioperative use of NSAIDs in humans on postoperative fracture/spinal fusion healing compared to other used analgesics measured as fracture nonunion with radiological control.
We performed a systematic literature search of the last 38 years using PubMed Embase and the Cochrane Controlled Trials Register including retro- and prospective clinical, human trials assessing the effect of NSAIDs on postoperative fracture/spinal fusion healing when used for perioperative pain management with a radiological follow up to assess eventual nonunion. Due to different study designs, drugs, dosages/exposition times and different methods to assess fracture nonunion, these studies were not pooled for a meta-analysis. A descriptive summary of all studies, level of evidence, study quality and study bias assessment using different scores were used.
Three prospective randomized controlled studies and thirteen retrospective cohort human studies were identified for a total of 12′895 patients. The overall study quality was low according to Jadad and Oxford Levels of Evidence scores.
Published results of human trials did not show strong evidence that NDAIDs for pain therapy after fracture osteosynthesis or spinal fusion lead to an increased nonunion rate. Reviewed studies present such conflicting data, that no clinical recommendation can be made regarding the appropriate use of NSAIDs in this context. Considering laboratory data of animal, human tissue research and recommendation of clinical reviews, a short perioperative exposition to NSAIDs is most likely not deleterious. However, randomized, controlled studies are warranted to support or refute this hypothesis.
•In vitro and animal studies suggest that the application for postoperative NSAIDs impair bone and tendon repair.•Human studies do not fully support in vitro and animal results.•Human data suggest that short term application of NSAIDs do not impair bone and tendon repair after orthopedic surgery.
Purpose
In spinal fusion surgery, imprecise placement of pedicle screws can result in poor surgical outcome or may seriously harm a patient. Patient-specific instruments and optical systems have been ...proposed for improving precision through surgical navigation compared to freehand insertion. However, existing solutions are expensive and cannot provide in situ visualizations. Recent technological advancement enabled the production of more powerful and precise optical see-through head-mounted displays for the mass market. The purpose of this laboratory study was to evaluate whether such a device is sufficiently precise for the navigation of lumbar pedicle screw placement.
Methods
A novel navigation method, tailored to run on the Microsoft HoloLens, was developed. It comprises capturing of the intraoperatively reachable surface of vertebrae to achieve registration and tool tracking with real-time visualizations without the need of intraoperative imaging. For both surface sampling and navigation, 3D printable parts, equipped with fiducial markers, were employed. Accuracy was evaluated within a self-built setup based on two phantoms of the lumbar spine. Computed tomography (CT) scans of the phantoms were acquired to carry out preoperative planning of screw trajectories in 3D. A surgeon placed the guiding wire for the pedicle screw bilaterally on ten vertebrae guided by the navigation method. Postoperative CT scans were acquired to compare trajectory orientation (3D angle) and screw insertion points (3D distance) with respect to the planning.
Results
The mean errors between planned and executed screw insertion were
3
.
38
∘
±
1.73
∘
for the screw trajectory orientation and 2.77±1.46 mm for the insertion points. The mean time required for surface digitization was 125±27 s.
Conclusions
First promising results under laboratory conditions indicate that precise lumbar pedicle screw insertion can be achieved by combining HoloLens with our proposed navigation method. As a next step, cadaver experiments need to be performed to confirm the precision on real patient anatomy.
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