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Volumetric analysis is being increasingly utilized in the preoperative evaluation of complex incisional hernias. Three-dimensional (3D) reconstruction of abdominal computed tomography (CT) scan has been used to obtain surface area (SA) and volume (Vol.) measurements, while others have used simple mathematical formulas to obtain SA and Vol. estimates without 3D reconstruction. Our objective was to assess the correlation of SA and Vol. measurements and estimates of complex incisional hernias. We conducted a retrospective agreement study of adults who underwent abdominal wall reconstruction from 2007 to 2018. Demographics, hernia characteristics, and operative data were collected from the medical record. SA and Vol. measurements were obtained after 3D CT reconstruction. Linear CT variables were obtained independently by two surgeons and SA and Vol. estimates were calculated. Because both surgeons reported similar results, only lead author values are reported in the abstract. We used Pearson’s correlation coefficient (r) to assess inter-rater agreement and the agreement between SA and Vol. measurements and estimates. A total of 108 patients were eligible for analysis. The mean age was 57 ± 11 years and 53 (49%) were female. 42 (39%) hernias were recurrent, 10 (9%) patients had a stoma, and 9 (8%) had a history of open abdomen. The mean defect width was 11 ± 4 cm and mean defect surface area (DSA) was 150 ± 95 cm2. Inter-rater agreement of SA and Vol. estimates was high (r ≥ 0.80). There was high correlation between SA and Vol. measurements and estimates for DSA, hernia sac volume (HSV), abdominal cavity volume (ACV), and HSV/ACV ratio (r = 0.81, 0.89, 0.94 and 0.91, respectively). SA and Vol. estimates demonstrated high level of agreement with SA and Vol. measurements using 3D reconstruction. SA and Vol. estimates can be obtained using simple mathematical formulas using easily obtained linear variables negating the need for the time and effort consuming 3D reconstruction.

The authors present a case report showing their experience with the use of PolyEtherEtherKetone (PEEK) implants as an innovative solution for the skeleton and soft tissues’ reshaping in facial aesthetic plastic surgery. This technique offers the surgeon a reliable and effective way to answer patients’ request of increasing volume and reshaping the malar area. A fifty-year-old patient complaining about hypoplasia of the malar area, after undergoing three operations of silicon implants’ placement and replacement, was still unsatisfied about the symmetry and feeling through the skin of the lower lid, the rim of the prostheses. The authors suggested the use of bone-anchored PEEK implants, to increase the volume and reshape the malar area by a skeleton and soft tissue camouflage. The treatment was planned and previewed on the preop 3-dimensional CT scans for the customization of the implants. Although no cases are reported in international literature on the use of this material in facial aesthetic surgery, this technique seems to offer a safe and effective solution for the treatment of patients asking to increase and modify the shape of their malar area. Custom made PEEK implants are already used in craniofacial reconstructive bony surgery with good results, and 3D CT scan planning is widely used in these cases. No complications were reported in the case reported and the outcomes seem to the authors and to the patient being, finally, satisfactory.

Glenoid bony lesions play a role in approximately half of anterior shoulder instability cases. The purpose of this study is to see if the anatomy of the coracoid affects the location of glenoid rim defects. We hypothesized that a prominent coracoid (lower and lateral) would be more likely to cause an anterior–inferior glenoid lesion, and a less prominent coracoid more prone to cause an anterior lesion. The null hypothesis being the absence of correlation. Fifty-one shoulder CT-scans from a prospective database, with 3D reconstruction, were analyzed. The position of glenoid lesions was identified using the validated clock method, identifying the beginning and end time. The size of bony glenoid defects was calculated using the validated glenoid ratio method. The position of the coracoid tip was measured in three orthogonal planes. Analysis included 25 right shoulders and 26 left shoulders in seven females and 41 males. The vertical position of the coracoid tip relative to the top of the glenoid was highly correlated to the location of the glenoid defect on the profile view (r = −0.625; 95% CI 0.423–0.768; p = 0.001). Thus, higher coracoids were associated with anterior lesions, while lower coracoids were associated with anterior–inferior lesions. A more laterally prominent coracoid was also correlated with anterior–inferior lesions (r = 0.433; 95% CI 0.179–0.633; p = 0.002). This study shows that coracoid anatomy affects the location of bony Bankart defects in anterior shoulder instability. Lower and laterally prominent coracoids are associated with anterior–inferior lesions. This variation in anatomy should be considered during pre-op planning for surgeries involving bone graft. Level 4 basic science.

Introduction Snapping shoulder syndrome could be effectively treated with scapulothoracic arthroscopy. The excision of the scapular superomedial corner is assumed to help lower the recurrence rate. However, the amount of resection is still controversial. Furthermore, we lack a technique to measure if the resected amount was adequate based only on arthroscopy evaluation. Case study presentation We describe a 47-year-old man who suffered from severe snapping shoulder syndrome as a consequence of a deformity of the left superomedial scapular corner. The patient had endoscopic bursectomy and superomedial corner resection. Intraoperative three-dimensional CT scans (3D-CT) were used to evaluate the amount of resection. The patient recovered without incident and resumed his usual activities within 30 days following surgery. At the six-month follow-up, there were no recurrent symptoms. Conclusion Intraoperative 3D imaging significantly enhances the safety and efficacy of scapulothoracic arthroscopy. This is a novel technique that, to our knowledge, has not been reported previously in the literature., Highlights • The scapular superomedial corner excision may help reduce recurrence rates of treatment for snapping shoulder syndrome. • The lack of anatomical landmarks makes estimating the resected volume by arthroscopic vision challenging. • This is the first report of the application of intra-operative 3D imaging for scapulothoracic arthroscopy. • Intraoperative 3D imaging significantly enhances the safety and effectiveness of scapulothoracic arthroscopy. • Intraoperative 3D imaging help in the precise identification of anatomical landmarks in small or complex regions.

Pediatric spinal injuries are very uncommon, accounting for a small percentage of all spinal injuries. Domestic accidents such as falling and bumping are frequent events during childhood. In this case report, we present a rare penetrating trauma by a cobbler's awl at the paraspinal level. The patient was referred to the ED after a needle became impaled into his back due to an accident that occurred at home. The patient's neurologic assessment was normal. A radiologic study of the patient showed a cobbler's awl penetrating the paravertebral muscle at the fourth lumbar vertebra level. The needle was removed promptly after an emergency surgical procedure. Postprocedure no complications occurred.

To determine how intraoperative assessment (engagement test) may affect recurrent dislocation rate and to compare the clinical outcomes, recurrence rates, and presence of on-/off-track conditions between cases that received arthroscopic Bankart repair alone (nonengaged Hill-Sachs lesion) and Bankart repair with remplissage (engaged Hill-Sachs lesion).We retrospectively reviewed 213 patients who underwent arthroscopic Bankart repair alone (186 patients with nonengaging lesions, group A) or with remplissage (27 patients with engaging lesion, group B) for recurrent anterior shoulder instability with25% glenoid bone defect. The presence of an engaging Hill-Sachs lesion was determined during arthroscopic evaluation. On-track or off-track lesions were assessed retrospectively from preoperative 3-dimensional (3D) computed tomography (CT).Mean glenoid bone defect was 13.7% in group A and 20.7% in group B (P.001). Off-track lesions were identified in 8.1% (15/186) and 100% (27/27) in group B. At the final follow-up (minimum 2 years; mean follow-up periods after surgery of 50.1 months in group A and 47.7 months in group B), there were no significant differences in shoulder functional scores and recurrence rates between groups, despite improvement after surgery. In the off-track lesion (group A-1: nonengaging but off-track lesion), recurrence instability occurred in 9 patients (60%, 9/15). Also, comparing group A-1 and group B, we noted significant differences in shoulder functional scores and recurrence rates (P.001).Of 186 patients, 8.1% with nonengaging Hill-Sachs lesions during direct arthroscopic examination under anesthesia actually demonstrated off-track lesions on preoperative 3D CT scans retrospectively, with 60% experiencing recurrent instability. Intraoperative manual assessment for Hill-Sachs engagement was inferior to 3D CT scan in establishing the presence of off-track defects.III, retrospective comparative study.

3D CT scan is actually the gold standard for preoperative diagnosis of pelvic discontinuity (PD) in hip revision surgery. Aim of this study was to compare the accuracy of 3D-modeling with traditional and 3D CT scan. We retrospectively identified 56 patients who underwent total hip arthroplasty revisions with Paprosky Type-3 periacetabular bone defects. Preoperative X-rays, CT scans and 3D-models were blindly reviewed by two orthopedic surgeons to detect possible pelvic discontinuities. Results were compared with surgical notes. Independent sensitivities, specificities, positive predictive values and negative predictive values were calculated for X-rays, CT scan and 3D models. Analysis of interobserver reliability was performed. Fifty-six patients met inclusion criteria. In nine patients, surgical notes indicated a pelvic discontinuity. On 3D CT scans, PD was identified in 25 cases for observer 1 and in 24 cases for observer 2. Analyzing 3D-models, PD was identified in eleven patients by both observers. The nine patients, with PD reported on the surgical report, were all identified with both the techniques. The specificity of standard 3D CT was 0.66 for observer 1 and 0.68 for observer 2 and increased to 0.96 for both observers with the utilization of 3D-models. The positive predictive value increased from 0.36 (observer 1) and 0.38 (observer 2) with the CT evaluation to 0.82 in the 3D-models evaluation. The analysis of 3D models was characterized by a perfect intraobserver reliability (intraobserver correlation coefficient = 1). The observers showed substantial agreement for PD classification; the kappa values were 0.96 and 0.77, respectively, for CT scan and 3D-model evaluation. 3D-modeling showed higher specificity than traditional and 3D CT scans in identification of PD in Paprosky Type-3 periacetabular bone defects.

Introduction When one of the anterior cruciate ligament (ACL) bundles is torn, it seems appropriate to preserve the remaining bundle to improve the vascularization and proprioception of the graft, and to reproduce the attachment sites of the torn bundle. After ACL reconstruction, the functional result is worse when the tunnels are positioned further away from the native ACL's isometric attachment points. The goal of this study was to use CT 3D reconstructions to analyse the position of the femoral tunnel following partial ACL reconstruction and to compare it to complete ACL reconstruction cases. We hypothesized that the femoral tunnel positioning was optimal during partial ACL reconstruction. Methods In this prospective single-centre study, 16 patients who underwent isolated anteromedial bundle reconstruction were evaluated during the immediate postoperative period using 3D reconstruction of CT images. During this same period, 180 patients who underwent complete ACL reconstruction in the same surgery unit served as a control group. Results In the partial ACL reconstruction group, 6 tunnels (37.5%) were in the optimal position and 10 tunnels (62.5%) were not. In the complete ACL reconstruction group, 124 femoral (68.9%) were in the optimal position and 56 (31.1%) were not ( P Discussion Femoral tunnel positioning is not always optimal in patients who undergo partial ACL reconstruction. Three-dimensional CT reconstruction is a good tool to help surgeons detect and learn from their errors. Level of evidence III (case-control study).

Postoperative reossification is a common clinical correlate following surgery. It has been suggested that an underexpression of transforming growth factor-β3 (TGF-β3) may be related to craniosynostosis and postoperative reossification. Adding TGF-β3 may delay reossification and improve postoperative growth. The present study was designed to test this hypothesis. Thirty 10-day-old New Zealand white rabbits with hereditary coronal suture synostosis were divided into three groups: (1) suturectomy controls (n = 14), (2) suturectomy treated with bovine serum albumin (n = 8), and (3) suturectomy treated with TGF-β3 protein (n = 8). At 10 days of age, a 3-mm × 15-mm coronal suturectomy was performed, and serial three-dimensional (3D) computed tomography (CT) scans and cephalographs were taken at 10, 25, 42, and 84 days of age. Calvaria were harvested at 84 days of age for histomorphometric analysis. Mean differences were analyzed using a group by age analysis of variance. Analysis of the 3D CT scan data revealed that sites treated with TGF-β3 had significantly (P < .05) greater defect areas and significantly (P < .05) greater intracranial volumes through 84 days of age compared with controls. Histomorphometry showed that sites treated with TGF-β3 had patent suturectomy sites and significantly (P < .001) less new bone in the suturectomy site compared with controls. Serial radiograph data revealed significant (P < .05) differences in craniofacial growth from 25 to 84 days in TGF-β3-treated rabbits compared with controls. Data show that TGF-β3 administration delayed reossification and improved craniofacial growth in this rabbit model. These findings also suggest that this molecular-based therapy may have potential clinical use.

Wajah terletak lebih ke anterior secara anatomis oleh sebab itu mudah mendapatkan trauma. Os Zigoma merupakan tulang yang menonjol pada wajah dan akan menahan gaya bentur terbesar pada wajah. Tulisan ini melaporkan penatalaksanan fraktur kompleks zigomatikomaksilaris sinistra dengan miniplate osteosynthesis. Seorang laki-laki 22 tahun dirujuk ke Bagian Bedah Mulut RSUP Dr Sardjito dengan riwayat kecelakaan lalulintas tiga minggu sebelum masuk RS. Pasien mengeluh daerah pipi kiri terasa tebal dan dirasa lebih datar dari pipi kanan. Pemeriksaan klinis terdapat parestesi nervus infraorbita sinistra , displace tulang daerah infraorbital rim sinistra , diskontinuitas regio sinus maksilaris sinistra. Radiografis CT axial dan koronal serta CT Scan 3D tampak fraktur melibatkan infraorbital rim sinistra, fraktur sinus maksila sinistra , fraktur pada sutura zigomaticofrontalis dan pada sutura zigomatikotemporalis. Penatalaksanaannya dilakukan open reduction internal fixation (ORIF) fraktur kompleks zigomatikomaksilaris dengan miniplate osteosynthesis di bawah anestesi umum. Pasca operasi gejala parestesi berangsur- angsur berkurang, defek infraorbital rim terkoreksi dan pipi kiri tampak kembali prominen. Prognosis kasus ini dubia ad bonam . ORIF dengan miniplate osteosynthesis dapat memulihkan deformitas wajah dengan hasil malar eminensia kembali prominen dan membuat kondisi dekompresi nervus infraorbita sinistra yang mendukung proses pemulihan sensorisnya. Management of Zygomaticomaxillaris Sinistra Complex Fractures with Osteosynthesis Miniplate . Face lies in a prominent position so that this area is often susceptible to trauma. Os zygomaticum is an area that holds the heaviest impact on facial trauma. This paper reports one case about zygomaticomaxillary complex fractures management with miniplate osteosynthesis. A 22 years old man was referred to the Department of Oral Surgery Dr Sardjito Hospital with a history of traffic accident three weeks before admission. He felt that his left cheek was thick and flatter than the right one. Clinical examination found that the left infraorbita nerve was paresthesized, the bone on the left infraorbital rim region was displaced and the left maxillary sinus region was discontinued. Radiography examination using CT axial and coronal, and 3D CT scan showed both of the left infraorbital rim and maxillary sinus were fractured, as well as the zygomaticotemporalis suture and the zygomaticofrontalis suture. An Open Reduction Internal Fixation (ORIF) of the zygomaticomaxillary complex fractures with miniplate osteosynthesis was performed under general anesthesia. The result showed that the postoperative paresthesia symptoms were gradually diminished, the infraorbital rim defects were corrected and the prominent left cheek was recontructed. The prognosis was dubia ad bonam. It can be concluded that ORIF with miniplate osteosynthesis reconstructs the facial deformity, recovers the malar eminence prominency. The nerves decompression will favor the recovery process of the left infraorbita sensory

The outcome of single-bundle anterior cruciate ligament (ACL) reconstruction depends largely on the anatomic placement of bone tunnel. The lateral intercondylar ridge (LIR) and bifurcate ridge (BR) are useful bony landmarks for femoral tunnel placement. The purpose of our study was to compare the bony landmarks of ACL footprint on femur by three-dimensional computed tomography (3D CT) scan and arthroscopy in chronic ACL-deficient knees. Fifty patients above 18 years of age who were diagnosed of having ACL tear were selected for the study. All the cases were more than 6 months old since the injury. Preoperative 3D CT scan of the affected knee was obtained for each of them. They underwent single-bundle anatomic ACL reconstruction. Measurements were done on the preoperative 3D CT and arthroscopy to quantify the position of the LIR and BR. The proximodistal distance of lateral femoral condyle was 21.41+/−2.5 mm on CT scan and 22.02+/−2.02 mm on arthroscopy. On preoperative 3D CT scan, the midpoint of the LIR was found to be located at a mean distance of 11.17±2.11 mm from the proximal margin of the lateral femoral condyle. On arthroscopy, it was at 10.18+/−1.52 mm from the proximal margin the lateral femoral condyle. The “bifurcate ridge”(BR) was not visible in any of the cases during arthroscopy or CT scan. We concluded that LIR is an easily identifiable bony landmark on arthroscopy in all cases. It can also be identified on CT scans. BR is not identified both on arthroscopy and CT scans in chronic ACL tears. The arthroscopic measurements of bony landmarks are quite close to those of CT scan. Midpoint of LIR is at 52.185% of the proximodistal distance on CT scan evaluation and it is at 46.21% on arthroscopic evaluation.

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision. A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings. At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system. We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful. 3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision. Cite this article: Bone Joint J 2015; 97-B:899–904.

International audience; IntroductionTreatment of medial tibiofemoral osteoarthritis with a high-tibial osteotomy (HTO) is most effective when the optimal angular correction is achieved. However, conventional instrumentation is limited when multiplanar correction is needed.HypothesisUse of patient-specific cutting guides (PSCGs) for HTO provides an accurate correction (difference < 2°) relative to the preoperative planning.Materials and methodsBetween February 2014 and February 2015, 10 patients (mean age: 46 years [range: 31–59]; grade 1 or 2 osteoarthritis in Ahlbäck's classification) were included prospectively in this reliability and safety study. All patients were operated using the same medial opening-wedge osteotomy technique. Preoperative planning was based on long-leg radiographs and CT scans with 3D reconstruction. The PSGCs were used to align the osteotomy cut and position the screw holes for the plate. The desired correction was achieved in the three planes when the holes on the plate were aligned with the holes drilled based on the PSCG. Preoperatively, the mean HKA angle was 171.9° (range: 166–179°), the mean proximal tibial angle was 87° (86–88°) and the mean tibial slope was 7.8° (1–22°). The postoperative correction was compared to the planned correction using 3D CT scan transformations. Intraoperative and postoperative complications were assessed at a minimum follow-up of 1 year.ResultsThe procedure was successfully carried out in all patients with the PSCGs. On postoperative long-leg radiographs, the mean HKA was 182.3° (180–185°); on the CT scan, the mean tibial mechanical angle was 94° (90–98°) and the mean tibial slope was 7.1° (4–11°). In 19 out of 20 postoperative HKA and slope measurements, the difference between the planned and achieved correction was < 2° based on the 3D analysis of the three planes in space; in the other case, the slope was 13° instead of the planned 10°. The intra-class correlation coefficients between the postoperative and planned parameters were 0.98 [0.92–0.99] for the HKA and 0.96 [0.79–0.99] for the tibial slope. There were no surgical site infections; one patient had a postoperative hematoma that resolved spontaneously.DiscussionThe results of this study showed that use of PSCGs in HTO procedures helps to achieve optimal correction in a safe and reliable manner.Level of evidenceIV – Prospective cohort study.Keywords: Medial tibiofemoral osteoarthritis, High tibial osteotomy, Opening-wedge osteotomy, Patient-specific surgical guides, 3D printing

Cranioplasty is considered a simple reconstructive procedure, usually performed in a single stage. In some clinical conditions, such as in children with multifocal flap osteolysis, it could represent a surgical challenge. In these patients, the partially resorbed autologous flap should be removed and replaced with a precustomed prosthesis which should perfectly match the expected bone defect. We describe the technique used for a navigated cranioplasty in a 3-year-old child with multifocal autologous flap osteolysis. We decided to perform a cranioplasty using a custom-made hydroxyapatite porous ceramic flap. The prosthesis was produced with an epoxy resin 3D skull model of the patient, which included a removable flap corresponding to the planned cranioplasty. Preoperatively, a CT scan of the 3D skull model was performed without the removable flap. The CT scan images of the 3D skull model were merged with the preoperative 3D CT scan of the patient and navigated during the cranioplasty to define with precision the cranioplasty margins. After removal of the autologous resorbed flap, the hydroxyapatite prosthesis matched perfectly with the skull defect. The anatomical result was excellent. Thus, the implementation of cranioplasty with image merge navigation of a 3D skull model may improve cranioplasty accuracy, allowing precise anatomic reconstruction in complex skull defect cases.

To assess whether there is a significant difference between the alignment of the individual femoral and tibial components (in the frontal, sagittal and horizontal planes) as calculated pre-operatively (digital plan) and the actually achieved alignment in vivo obtained with the use of patient-specific positioning guides (PSPGs) for TKA. It was hypothesised that there would be no difference between post-op implant position and pre-op digital plan.Twenty-six patients were included in this non-inferiority trial. Software permitted matching of the pre-operative MRI scan (and therefore calculated prosthesis position) to a pre-operative CT scan and then to a post-operative full-leg CT scan to determine deviations from pre-op planning in all three anatomical planes.For the femoral component, mean absolute deviations from planning were 1.8A degrees (SD 1.3), 2.5A degrees (SD 1.6) and 1.6A degrees (SD 1.4) in the frontal, sagittal and transverse planes, respectively. For the tibial component, mean absolute deviations from planning were 1.7A degrees (SD 1.2), 1.7A degrees (SD 1.5) and 3.2A degrees (SD 3.6) in the frontal, sagittal and transverse planes, respectively. Absolute mean deviation from planned mechanical axis was 1.9A degrees. The a priori specified null hypothesis for equivalence testing: the difference from planning is > 3 or

Background Type B glenoids according to Walch are subclassified into a group with no posterior erosion (B1) and a group with important posterior erosion (B2) based on 2-dimensional axial computed tomography (CT) scan images. Three-dimensional (3D) CT scan reconstruction seems to improve the accuracy of the measurement of erosion because of its independence from positional errors. The aim is to quantify the direction and amount of posterior erosion of type B glenoids using a reproducible 3D measuring technique. Methods We performed 3D reconstruction of 72 type B glenoids (24 type B1 glenoids and 48 type B2 glenoids) using Mimics (Materialise, Haasrode, Belgium). The native glenoid plane and intermediate glenoid plane were determined by use of 3-Matic (Materialise). The normal glenoid version, eroded retroversion, and difference in retroversion were measured. Next, the maximum erosion and its orientation were quantified. Results There was always minimum erosion of 1.7 mm, and the mean erosion was 4.2 mm. There was a significant difference between the mean erosion in type B1 glenoids (3.5 mm) and type B2 glenoids (4.5 mm) ( P = .019). The mean orientation of the erosion was mostly to the posteroinferior side (119°; SD, 26.8). There was a significant difference between the mean orientation in type B1 glenoids (132°; SD, 25.2) and type B2 glenoids (113°; SD, 25.5) ( P = .004). Conclusions With the use of this newly developed reproducible measuring technique, the maximum erosion in type B glenoids can be adequately quantified. All glenoids showed signs of important erosion. Because the orientation of the maximum erosion in type B1 glenoids is situated more inferiorly, the 2-dimensional CT scan technique can be insufficient to evaluate this erosion.

The purpose of this article was to demonstrate an anterior cruciate ligament (ACL) reconstruction technique using oval tunnels. Aim of this single bundle technique is to fit the footprint anatomy of the ACL as closely as possible. TECHNIQUE AND PATIENTS: The presented technique is a single bundle technique using a semitendinosus graft. For femoral tunnel placement, a specific medial portal aimer (Karl Storz, Tuttlingen, Germany) is used. Aiming and drilling of the femoral tunnel are performed via the medial portal. Oval tunnels are created by stepwise dilatation with ovally shaped dilatators. The position of the femoral tunnel is visualized and controlled with the arthroscope via the medial portal. For the tibial tunnel placement, a specific aimer was used as well. With this technique, 24 patients were operated and all intra- and postoperative complications were analyzed prospectively. The tunnel position was documented postoperatively by CT scan.There were no significant intra- and postoperative complications associated with the oval tunnel technique. The postoperative 3D CT scan revealed that all femoral and tibial tunnels were located within the area of the anatomical ACL insertions.This article presents an ACL reconstruction technique using oval dilatators and medial portal aimers to create oval tunnels. These oval tunnels match the insertion site anatomy much closer than round tunnels do.Level IV, case series.

Simultaneous post-traumatic ipsilateral fracture of femur head and subcapital femur neck without hip dislocation is a rare presentation and easily missed on X-ray imaging. A 48 years old male, with a history of high-energy road traffic accident, presented to us with severe pain in the left hip region and inability to ambulate. Preliminary X-ray showed impacted subcapital fracture with varus angulation between femur head and neck. Further computed tomography (CT) scan imaging showed ipsilateral fracture of femur head and subcapital femur neck without hip dislocation. Primary total hip arthroplasty was performed. Presently patient is 5 years post-surgery and can ambulate without support. In conclusion, this fracture pattern, though rare, should be suspected in high-energy road traffic accident patients with shear forces acting at femur neck. It can best be diagnosed using 3D CT scan imaging. Primary total hip arthroplasty is an appropriate treatment in such patients.

Background Long-leg radiographs (LLR) are often used in orthopaedics to assess limb alignment in patients undergoing total knee arthroplasty (TKA). However, there are still concerns about the adequacy of measurements performed on LLR. We assessed the reliability and validity of measurements on LLR using three-dimensional computed tomography (3D CT)-scan as a gold standard. Methods Six different surgeons measured the mechanical axis and position of the femoral and tibial components individually on 24 LLR. Intraclass correlation coefficients (ICC) were calculated to obtain reliability and Bland–Altman plots were constructed to assess agreement between measurements on LLR and measurements on 3D CT-scan. Results ICC agreement for the six observer measurements on LLR was 0.70 for the femoral component and 0.80 for the tibial component. The mean difference between measurements performed on LLR and 3D CT-scan was 0.3° for the femoral component and − 1.1° for the tibial component. Variation of the difference between LLR and 3D CT-scan for the femoral component was 1.1° and 0.9° for the tibial component. 95% of the differences between measurements performed on LLR and 3D CT-scan were between − 1.9 and 2.4° (femoral component) and between − 2.9 and 0.7 (tibial component). Conclusion Measurements on LLR show moderate to good reliability and, when compared to 3D CT-scan, show good validity. Clinical trial registration number: institutional review board Atrium-Orbis-Zuyd, number: 11-T-15. Level of Evidence Prospective cohort study, Level II.

Object The treatment of basilar invagination in the pediatric age group is dependent on the possibility of preoperative reduction. Reducible lesions obviate a ventral decompression and require a dorsal-only approach for stabilization with or without a suboccipital decompression. Methods The authors describe a technique of intraoperative reduction of basilar invagination with the use of general anesthesia and neuromuscular blockade in the presence of crown halo traction. Using the O-arm device, a 3D CT scan is generated in the sagittal plane to demonstrate the reduction intraoperatively. This technique was successful in 6 pediatric patients with basilar invagination. Results The average age of the patients was 10.8 years, and they were followed for a mean period of 8.5 months. The patients had mild basilar invagination or partial reduction in extension on preoperative MR imaging. Intraoperative reduction was demonstrated in all patients by using the reported technique with intraoperative CT. All patients underwent occipitocervical fusion, and all but one underwent a suboccipital decompression. There were no complications related to the operation, and all but one reported improvement of symptoms on the last postoperative visit. Conclusions Intraoperative reduction performed using neuromuscular blockade and intraoperative traction is an effective method for further reduction of basilar invagination in the pediatric age group. This is the first reported application of intraoperative CT imaging performed using the O-arm device in craniocervical surgery in which successful reduction is demonstrated in detail.

The purpose of the study was to determine the normal three-dimensional relationship between the humeral and the glenoid plane of the individual patient. We measured the three-dimensional angle between the glenoid plane and the humeral plane (glenohumeral angle, °GH) and the angle between the plane of the scapula and the plane of the glenoid (glenoscapular angle, °GS) with the patient in a standardized position to the CT scan gantry. We hypothesized that a normal distribution with a small variation would exist for both angles.A total of 150 conventional CT scans of normal shoulders from patients aged between 18 and 80 years were examined and three-dimensional reconstructions were derived from it. The descriptive statistics and the variability of °GH and °GS were determined.The mean °GH was 57.9°, and the mean °GS was -3.77°. The overall reliability of the measurement was good. Descriptive statistics of this study confirm the normal distribution and a narrow variation of both parameters.This is the first study to determine the normal 3D relationship between the humerus and the glenoid (°GH). This new three-dimensional anatomical information of the normal glenohumeral relationship and glenoid can be used to distinguish normal from pathological anatomy, as well as alternative surgical guidance especially in bony deficient glenoids. Level of Evidence Level II Anatomical Study.

Introduction Conventional cephalometry is an inexpensive and well-established method for evaluating patients with dentofacial deformities. However, patients with major deformities and in particular asymmetric cases are difficult to evaluate by conventional cephalometry. Reliable and accurate evaluation in the orbital and midfacial region in craniofacial syndrome patients is difficult due to inherent geometric magnification, distortion and the superpositioning of the craniofacial structures on cephalograms. Both two- and three-dimensional computed tomography (CT) have been proposed to alleviate some of these difficulties. Aims and objectives The aim of our study is to compare the reliability of anatomic cephalometric points obtained from the two modalities: Conventional posteroanterior cephalograms and 3D CT of patients with facial asymmetry, by comparison of intra- and interobserver variation of points recorded from frontal X-ray to those recorded from 3D CT. Materials and methods The sample included nine patients (5 males and 4 females) with an age range of 14 to 21 years and a mean age of 17.11 years, whose treatment plan called for correction of facial asymmetry. All CT scans were measured twice by two investigators with 2 weeks separation for determination of intraobserver and interobserver variability. Similarly, all measurement points on the frontal cephalograms were traced twice with 2 weeks separation. The tracings were superimposed and the average distance between replicate points readings were used as a measure of intra- and interobserver reliability. Intra-and interobserver variations are calculated for each method and the data were imported directly into the statistical program, SPSS 10.0.1 for windows. Results Intraobserver variations of points defined on 3D CT were small compared with frontal cephalograms. The intraobserver variations ranged from 0 (A1, B1) to 0.6 mm with the variations less than 0.5 mm for most of the points. Interobserver variations of points between first and second tracings defined on PA Ceph and 3D CT were less than 1.5 mm for all the points. A direct comparison of frontal cephalometry and 3D CT using intraobserver variation for the first observer showed that 3D CT was more reliable than frontal cephalometry for 11 points. Direct comparison of frontal cephalometry and 3D CT for the second observer showed a similar tendency with 14 points significantly more reliable for 3D CT. Comparison of frontal cephalometry and 3D CT using interobserver variation for the tracings showed that 3D CT was more reliable than frontal cephalometry. Summary and conclusion The study has shown that 3D CT is consistently more accurate and reliable than conventional frontal cephalometry. Unfortunately, the cost of a computerized tomography examination is considerable; this means that, at this stage, its use by surgeons and orthodontists is a last resort.

Introduction Seventeen patients diagnosed with cerebral palsy were studied to assess the results of X-rays vs. 3D CT scans of the hip. Materials and methods 3 X-ray parameters were compared with 4 3D CT scan parameters. Results The results obtained showed a significant correlation between X-rays and CT scans. According to the assessment of the Weinberg Central Edge (CE) angle there were 28 dysplastic hips and 6 normal hips. According to the Reimers index there were 29 dysplastic hips and 5 normal hips. According to the acetabular index there were 30 subluxated hips and 4 normal hips. Using CT scan parameters the mean value of the femoral neck-shaft angle was 147.09° (range: 127°-175°), a higher-than-normal figure. The mean value of the femoral anteversion angle was 33.43° (range 9°-50°), also higher than usual. The mean axial acetabular index was 120.29°, with a normal value of 101.6° at 9 years of age associated with acetabular flattening. The mean acetabular anteversion angle was 13.11° (range 7°-24°), which indicated a parity of results. Conclusions X-rays are necessary for the diagnosis and prognosis of hip dysplasia. Acetabular coverage and presurgery assessment and planning must be done based on 3D CT scans.

Optical Coherence Tomography (OCT) has extensive potential for producing clinical impact in the field of neurological diseases. A neurosurgical OCT hand-held forward viewing probe in Bayonet shape has been developed. In this study, we test the feasibility of integrating this imaging probe with modern navigation technology for guidance and monitoring of skull base surgery. Cadaver heads were used to simulate relevant surgical approaches for treatment of sellar, parasellar and skull base pathology. A high-resolution 3D CT scan was performed on the cadaver head to provide baseline data for navigation. The cadaver head was mounted on existing 3- or 4-point fixation systems. Tracking markers were attached to the OCT probe and the surgeon-probe-OCT interface was calibrated. 2D OCT images were shown in real time together with the optical tracking images to the surgeon during surgery. The intraoperative video and multimodality imaging data set, consisting of real time OCT images, OCT probe location registered to neurosurgical navigation were assessed. The integration of intraoperative OCT imaging with navigation technology provides the surgeon with updated image information, which is important to deal with tissue shifts and deformations during surgery. Preliminary results demonstrate that the clinical neurosurgical navigation system can provide the hand held OCT probe gross anatomical localization. The near-histological imaging resolution of intraoperative OCT can improve the identification of microstructural/morphology differences. The OCT imaging data, combined with the neurosurgical navigation tracking has the potential to improve image interpretation, precision and accuracy of the therapeutic procedure.

The anteroposterior talocalcaneal angle (Kite's angle) is still considered a common parameter for assessing clubfoot correction, although some dissenting opinions about its accuracy have been expressed. The purpose of this study was to evaluate the validity of the anteroposterior talocalcaneal angle for assessing correction of congenital clubfoot in adults who received the treatment as children. SUBJECTS AND METHODS. The anteroposterior talocalcaneal angle was measured in 48 treated idiopathic congenital clubfeet and 28 normal feet of 38 patients at the end of skeletal growth using both standing anteroposterior radiographs and 3D CT scan reconstructions. All the patients had been treated by manipulation, above-the-knee casting, and a complementary posteromedial release operation.The radiographic measurement of the anteroposterior talocalcaneal angle corresponded to the measurement of the same angle on the 3D CT scan reconstructions in only the normal feet and 12 clubfeet. In the other 36 clubfeet, a statistically significant difference of a mean of 15 degrees between the two measurements was noted, and the 3D CT scan reconstructions showed a superimposition of the talus and calcaneus, which had lost their normal anatomic divergence. In these cases, the marked medial angulation of the talar neck allowed a positive measurement of the anteroposterior talocalcaneal angle in the anteroposterior radiographic projection.According to our findings, the measurement of the anteroposterior talocalcaneal angle on radiography was misleading for assessing the degree of hindfoot correction in 75% of the treated congenital clubfeet. We believe that other imaging parameters should be considered instead of this angle to evaluate clubfoot correction.

A 9-year-old girl was referred to a trauma centre with severe head injury. 3D CT scan revealed depressed fracture involving the frontal bone on the right side, right parietal bone, and right superior orbital margin, right lamina papyracea. The frontal table was managed conservatively and open reduction and internal fixation was done for the supraorbital blow in to correct the ocular dystopia. The clinical course, possible mechanism, and management of the patient are discussed.

BackgroundDuring a pancreatectomy, the left gastric vein (LGV) has an important role in the venous drainage of the stomach (total pancreatectomy, left splenopancreatectomy, pancreatoduodenectomy with venous resection and pylorus-preserving pancreaticoduodenectomy). Pre-operative knowledge of the LGV's termination is necessary for adequate protection of this vein during dissection. The objective of the present study was to analyse the location of the LGV's termination in a patient population and facilitate its identification in at-risk situations.Materials and methodsAbdominal computed tomography (CT) images of 86 pancreatic tumour patients (20 of whom underwent surgery), who were treated in our institution between October 2009 and October 2010, were reviewed. Arterial-phase and portal-phase helical CT with three-dimensional reconstruction was performed in all cases. The location of the termination of the LGV was determined and (when the LGV merged with the splenic vein or the splenomesenteric trunk) the distance between the termination and the origin of the portal vein (PV). The correlation between CT imaging data and intra-operative findings was studied.ResultsThe LGV was identified on all CT images. In 65% of cases (n= 56), the LGV terminated in the PV (upstream of the liver in nine of these cases). The LGV terminated at the splenomesenteric trunk in 4.7% of cases (n= 4) and in the splenic vein in 30.3% of cases (n= 26). When the LGV terminated upstream of the origin of the PV, the distance between the two was always greater than 1cm. The average distance between the termination of the LGV and the origin of the PV was 14.34mm (10.2 to 21.1). The anatomical data from CT images agreed with the intra-operative findings in all cases.ConclusionPre-operative analysis of the LGV is useful because the vein can be identified in all cases. Knowledge of the termination's anatomic location enables the subsequent resection to be initiated in a low-risk area.

Background The location and degree of bony defects that can affect clinical outcomes remains controversial in recurrent shoulder dislocation. The purpose of this study was to define the most common location of glenoid bony defects in patients with recurrent shoulder dislocation. Materials and methods We analyzed the shape and aspect ratio of 44 glenoids from deceased donors. Glenoid size was analyzed using a 3-dimensional (3D) computed tomography (CT) scan in 24 patients with recurrent shoulder dislocation who underwent arthroscopic Bankart repair. We measured the distances from the center of the longitudinal axis of the glenoid to the anterior glenoid rim at 9 positions, 10° apart, from 3:00 to 6:00 o'clock positions in the cadaver and patient groups. We compared the quantification of glenoid defects in the 24 patients using the 3D CT scan. A predictive model based on a discriminant analysis was developed. Results The largest length differences of the glenoid were at the 3:20 o'clock position. When percentage of bone antidefect of the 3:20 o'clock position was used, the model predicted the existence of a defect with 89.7% hit ratio. Conclusions The major direction of the glenoid defect was in a more anterior position rather than the anteroinferior glenoid in patients with recurrent shoulder dislocation. The 3:20 o'clock position was most common location of glenoid defect in shoulder instability. This pattern of bone loss should be considered by the surgeon when operating on these patients, especially when performing arthroscopic procedures for Bankart repair or bone block operations to the glenoid.

Three-dimensional computed tomographic scanning alone often gives inconclusive results in the area of the medial wall and floor of the orbit because the method of three-dimensional rendering is still not perfect and obviously cannot reconstruct these thin bony walls effectively and is not the preferred method for evaluating orbital walls.

Concerning acetabular fractures, the three-dimensional (3D) CT-scan computer reconstructions has been acknowledged in recent times as a useful adjunct in preoperative setting up (1) since it can be used as a qualitative and quantitative instrument for the diagnosis of a variety of hip diseases and for the planning of precise surgical procedures (2). Proper software enables the computer to integrate the data of the individual thin CT slices to make three dimensional volumetric rendering information, therefore enabling preoperative computer simulated plannings of internal fixations and of reduction control intraoperatively. Moreover the actual SpiralCT scanners are almost equivalent in costs and in total radiation dose when compared to the performance of special projections of usual radiographs (3). The capability to rotate the 3D images around a variety of axes (Fig. 1) allows the construction of exceptional images that offer perspectives unobtainable by conventional radiology (4), carrying out a complete model with both external and internal surfaces of the injured site without destroying it. 3D images allow a useful display of the fracture, its irradiation and the dislocation of bone fragments (5), facilitating not only the analysis and detection of post-traumatic dislocations, but also the existence of neoplastic changes or disturbances in the mechanics of joints (6). What is more, when a hip fracture is only suspected but not clearly showed on plain radiographs, a CT scan with 3D reconstruction may be helpful, since it illustrates, when present, the angle and displacement of the fracture. In conclusion, we recommend that you bear in mind the 3D CT scan reconstruction as a useful complementary radiographic examination for complicated hip fractures/dislocations patterns. Don’t forget the 3D-CT scan in hip traumatology surgery!

Purpose: We describe a noninvasive radiologic evaluation of a retrocaval ureter using currently available technology. Materials and Methods: Three-dimensional volume-rendered CT and diuretic renography were performed for evaluation of a possible retrocaval ureter. Results: The 3D CT scan definitively diagnosed the retrocaval ureter, while diuretic renography showed no evidence of clinically significant obstruction. No invasive procedures were required. Conclusion: A 3D volume-rendered CT scan in the excretory phase combined with diuretic renography is the radiologic evaluation of choice for patients with a suspected retrocaval ureter, as it is noninvasive yet highly accurate in its anatomic delineation.

To study the effect of the degree of scoliosis, degree of hypokyphosis/lordosis and rotation of apical vertebra on individual lung volume (measured with CT scan) in asymptomatic adolescent idiopathic scoliosis (AIS) patients. Individual (right and left) lung volume, angle of kyphosis and rotation of apical vertebra, were measured in 77 asymptomatic AIS patients having right thoracic curve, using modern computed tomography (CT) scan. To compare, lung volumes were measured in 22 normal persons (control group). The ratio of "right to left lung volume (convex to concave side)" was obtained and compared among these groups. With increased Cobb's angle, ratio of convex to concave lung volume increased. For Cobb's angle more than 40 degrees, it was increased significantly (P = 0.0042). A significant degree of correlation was found between axial rotation angle of apical vertebra and right to left lung volume ratio (P = 0.0067, r = 0.271). A significant inverse correlation was found between the angle of kyphosis and right to left lung volume ratio, i.e., as the angle of kyphosis decreased the convex to concave lung volume ratio increased (P = 0.0109, r = -0.255). In asymptomatic, AIS patients, with increase in degree of curvature, and rotation of apical vertebra, the ratio of convex to concave side lung volume increases; indicating concave side lung volume is comparatively more affected (decreased) than convex side lung volume. On the other hand with decrease in the angle of kyphosis the convex to concave lung volume ratio increases indicating kyphotic angle has an inverse relation to convex to concave lung volume ratio.

Background: Retrieved metal-on-metal acetabular cups are valuable resources in investigating the wear behaviour of failed hip implants, but adequate methods to do so are lacking. To further contribute to addressing this issue, we developed a method to detect the in vivo location of the primary wear scar of an explanted cup. Methods: We proposed a new method in which thirteen patients with failed metal hip resurfacings were recruited, and their acetabular components retrieved. A 3D wear map was generated and the precise location of the primary wear scar in each cup was identified using a coordinate measuring machine. This wear scar location was noted in relation to the features on the acetabular cup. Having identified the location of the wear scar, this 3D positional map was co-registered to the implant on the patient’s pelvic 3D CT scan. Results: Using our proposed technique, we were able to demonstrate that the in vivo position of the primary wear scar in explanted metal acetabular cups can be variable. Conclusions: This method has utilised existing techniques to better understand the three-dimensional properties of wear behaviour, and may be a method which can be used in further studies to investigate variables that affect the position of the primary wear scar.