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Background Meniscus allograft transplantation is a valuable surgical option for post-meniscectomy syndrome. For best results, the selected allograft should be as similar as possible to the original meniscus. Three-dimensional meniscus sizing could be a new approach to improve the accuracy of meniscus matching. The contralateral anatomy might therefore be a suitable reconstruction template. The purpose of this study was to compare the three-dimensional shape of the right and left menisci by bi-planar segmentation of magnetic resonance imaging (MRI) scans. Methods Three-dimensional surface models of healthy menisci were created based on 40 bilateral MRI scans. Manual segmentation was performed on the MRI data in sagittal and coronal planes. For side-to-side comparison, each left meniscus model was mirrored and then superimposed to its corresponding right meniscus model. Differences between the meniscus pairs were assessed by width, length, height and surface distances. Inter-reader reliability, as well as accuracy of bi-planar segmentation was assessed by two different readers. Results The meniscus pairs were not significantly different in terms of width, length and height (P = at least 0.138). Side difference of mean surface distances was 0.76 mm (± 0.13 standard deviation (SD)) for medial and 0.78 mm (± 0.15 SD) for lateral menisci. Inter-reader reliability was good to excellent (0.828–0.987). Conclusion The three-dimensional shapes of the left and right menisci are very similar. Therefore, the contralateral meniscus can be used as a template for three-dimensional meniscus allograft sizing. Three-dimensional meniscus segmentation and sizing can be performed accurately by combination of sagittal and coronal planes.

Background The region around the knee joint is a common location of malignant bone tumours. Limb salvage procedures, whenever possible, are preferred to amputation. Allograft reconstruction is an accepted procedure to restore large bone defects. Preoperative three-dimensional (3D) planning and patient-specific instruments (PSI) have already been introduced. The purpose of this study was to provide a technical guideline for joint preserving tumour resection and allograft reconstruction around the knee using 3D planning and PSI. Material and methods 3D triangular surface models are created based on computed tomography (CT) and magnetic resonance imaging (MRI) data, whereby tumour expansion in the bone and affection of the surrounding structures are assessed. We describe the preoperative 3D analysis and planning in tumours around the knee joint. In addition, we provide a description of different PSI as well as cutting-techniques to enlarge the toolkit and facilitate a broad range of joint preserving tumour resections with allograft reconstruction around the knee. The basic guide serves for the registration of the preoperative plan for the surgery. Reference pins facilitate the application of further guides. Different additional guide designs can be applied, such as “safety guides,” “osteotomy guides,” and “allograft adjustment guides.” Discussion The use of 3D planning and generation of PSI offers valuable tools in tumour resection and allograft reconstruction around the knee joint. To perform complex osteotomies and to preserve vital structures PSI seems to be helpful tools. A step-by-step guideline is provided for the use of 3D preoperative planning and sequentially applied patient-specific guides.

Medial open wedge high tibial osteotomy (MOWHTO) is an effective treatment option for realignment of a varus knee. However, a simple supra-tuberositary osteotomy can lead to patella baja and potentially increases the tibial tuberosity-trochlear groove distance (TTTG). The purpose of this study was to quantify the influence of MOWHTO on TTTG.Three-dimensional (3D) surface models of five lower extremities with a varus hip-knee-ankle angle (HKA) and a borderline TTTG (≥ 15 mm), five lower extremities with a varus HKA and a normal TTTG ( 15 mm) and a 3D statistical shape model (SSM) of a neutrally aligned healthy knee were analysed by simulating MOWHTO with a stepwise increment of one degree of valgisation from the preoperative coronal deformity (0°-15°) for each patient, resulting in a total of 165 simulations. Postoperative 3D TTTG and tibial torsion (TT) were measured for each simulation. A mathematical formula was developed to calculate the increase of TTTG after MOWHTO. Mean differences between simulated and calculated TTTG were analysed.Mean preoperative HKA was 6.5 ± 3.0° varus (range 0.8°-11.5°). Mean TTTG increased from 14.2 ± 3.2 mm (range 9.6-19.1) preoperatively to 18.8 ± 3.8 mm (range 14.5-25.0) postoperatively (p = 0.001). TTTG increased approximately linear by + 0.5 ± 0.2° (range 0.3-0.8) per 1° of valgisation with a high positive correlation (0.99, p = 0.001) from 0° to 15°. Mean difference between simulated and calculated TTTG was 0.03 ± 0.02 mm (range 0.01-0.07) per 1° of valgisation (p 0.001).MOWHTO results in an approximately linear increase in TTTG of + 0.5 mm per 1° of valgisation in the range from 0° to 15° and the lateralisation of the tibial tuberosity can be calculated reliably using the described formula. Preoperative analysis of TTTG in patients undergoing MOWHTO may prevent unintentional patellofemoral malalignment.III.

Background: The isometric characteristics of nonanatomic and anatomic posterolateral corner (PLC) reconstruction techniques under weightbearing conditions remain unclear. Purpose: To (1) simulate graft elongation patterns during knee flexion for 3 different PLC reconstruction techniques (Larson, Arciero, and LaPrade) and (2) compute the most isometric insertion points of the fibular collateral ligament (FCL) graft strands for each technique and report quantitative radiographic landmarks. Study Design: Descriptive laboratory study. Methods: The authors performed a 3-dimensional simulation of 10 healthy knees from 0° to 120° of flexion using weightbearing computed tomography (CT) scans. The simulation was used to calculate ligament length changes during knee flexion for the PLC reconstruction techniques of Larson (nonanatomic single-bundle fibular sling reconstruction), Arciero (anatomic reconstruction with additional popliteofibular ligament graft strand), and LaPrade (anatomic reconstruction with popliteofibular ligament graft strand and popliteus tendon graft strand). The most isometric femoral insertion points for the FCL graft strands were computed within a 10-mm radius around the lateral epicondyle (LE), using an automatic string generation algorithm (0 indicating perfect isometry). Radiographic landmarks for the most isometric points were reported. Results: Median graft lengthening during knee flexion was similar for the anterior graft strands of all 3 techniques. The posterior graft strands demonstrated significant differences, from lengthening for the Arciero (9.9 mm [range, 6.7 to 15.9 mm]) and LaPrade (10.2 mm [range, 4.1 to 19.7 mm]) techniques to shortening for the Larson technique (−17.1 mm [range, −9.3 to −22.3 mm]; P < .0010). The most isometric point for the FCL graft strands of all techniques was located at a median of 2.2 mm (range, −2.2 to 4.5 mm) posterior and 0.3 mm (range, −1.8 to 3.7 mm) distal to the LE. Conclusion: Overconstraint can be avoided by tensioning the posterior graft strands in the Larson technique in extension, and in the Arciero and LaPrade techniques at a minimum of 60° of knee flexion. The most isometric point was located posterodistal to the LE. Clinical Relevance: The described isometric behavior of nonanatomic and anatomic PLC reconstruction techniques can guide optimal surgical reconstruction and prevent graft lengthening and overconstraint of the lateral compartment in knee flexion. Repetitive graft lengthening has been found to be associated with graft failure, and overconstraint favors lateral compartment pressure and cartilage degeneration.

Background Preoperative templating in total hip arthroplasty (THA) is mandatory to achieve appropriate offset and leg length equality. However, templating methods using the contralateral hip might be susceptible to errors resulting from side-differences in the femoral morphology. The distance of the lesser trochanter to the femoral head center (LTFHD) is a frequently used reference parameter for preoperative planning and intraoperative validation during THA. However, currently no three-dimensional (3D) analysis of side differences of the LTFHD exists. Methods Using Computer tomography (CT)-based surface models from 100 paired femora (50 cadavers), side-to-side asymmetry of the LTFHD, femoral length, femoral head diameter (FHD) and femoral antetorsion were analyzed. Univariate linear regression models were established to evaluate potential associations between sides regarding LTFHD and FHD as well as a correlation of these parameters with each other. Results Statistically significant side-differences were found for the LTFHD (p = 0.02) and FHD (p = 0.03) with a mean absolute side-difference of 1.6 ± 1.4mm (range 0.1–5.5mm) and 0.4mm ± 0.6mm (range 0–3mm), respectively. The ratio between the LTFHD and FHD was consistent with an average value of 1.16 ± 0.08 and reliable between sides with a correlation coefficient (r) of 0.72 (p Conclusions The LTFHD is a reliable reference parameter for preoperative templating and intraoperative validation during THA with a high correlation between sides (r = 0.93, p

Flexion and rotation of the knee joint are supposed to alter the measurement of the mechanical leg axis on long leg radiographs. However, in patients with varus or valgus alignment it has not been systematically analyzed so far. The hypothesis is that measurement of the mechanical leg axis is more influenced by flexion and rotation in presence of varus or valgus alignment compared to patients with a straight coronal alignment. 3D surface models of the lower extremities of seven individuals with varying degrees of coronal alignment were created based on CT data. The coronal alignment of the seven individuals captured the range between 9° varus and 9° valgus with equal steps of 3°. Combinations of internal and external rotations of 10°, 20°, and 30° with flexion of 5°, 10°, 15°, 20°, and 30° were simulated. The mechanical leg axis was measured for each combination as the antero-posterior (ap)-projected hip–knee–ankle (HKA-) angle. 294 simulations with all combinations of rotation and flexion were performed. Ranges of deviation of HKA never showed a critical deviation of more than 3° from median values. Deviations from baseline appeared normally distributed for all flexion and rotation combinations (p

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 Selection of a meniscus allograft with a similar three-dimensional (3D) size is essential for good clinical results in meniscus allograft surgery. Direct meniscus sizing by MRI scan is not possible in total meniscectomy and indirect sizing by conventional radiography is often inaccurate. The purpose of this study was to develop a new indirect sizing method, based on the 3D shape of the ipsilateral tibia plateau, which is independent of the meniscus condition. Methods MRI and CT scans of fifty healthy knee joints were used to create 3D surface models of both menisci (MRI) and tibia plateau (CT). 3D bone models of the proximal 10 mm of the entire and half tibia plateau (with / without intercondylar area) were created in a standardized fashion. For each meniscus, the best fitting “allograft” couple out of all other 49 menisci were assessed by the surface distance of the 3D meniscus (best available allograft), of the 3D tibia plateau (3D-CT) and by the radiographic method of Pollard (2D-RX). Results 3D-CT sizing was significantly better by using only the half tibia plateau without the intercondylar area (p Conclusions Automatized, indirect meniscus sizing using the 3D bone models of the tibia plateau is feasible and more precise than the previously described 2D-RX method.. However, further technical improvement is needed to select always the best available allograft.

Background Inaccurate meniscus allograft size is still an important problem of the currently used sizing methods. The purpose of this study was to evaluate a new three-dimensional (3D) meniscus-sizing method to increase the accuracy of the selected allografts. Methods 3D triangular surface models were generated from 280 menisci based on 50 bilateral and 40 unilateral knee joint magnetic resonance imaging (MRI) scans. These models served as an imaginary meniscus allograft tissue bank. Meniscus sizing and allograft selection was simulated for all 50 bilateral knee joints by (1) the closest mean surface distance (MeSD) (3D-MRI sizing with contralateral meniscus), (2) the smallest meniscal width/length difference in MRI (2D-MRI sizing with contralateral meniscus), and (3) conventional radiography as proposed by Pollard (2D-radiograph (RX) sizing with ipsilateral tibia plateau). 3D shape and meniscal width, length, and height were compared between the original meniscus and the selected meniscus using the three sizing methods. Results Allograft selection by MeSD (3D MRI) was superior for all measurement parameters. In particular, the 3D shape was significantly improved (p < 0.001), while the mean differences in meniscal width, length, and height were only slightly better than the allograft selected by the other methods. Outliers were reduced by up to 55% (vs. 2D MRI) and 83% (vs. 2D RX) for the medial meniscus and 39% (vs. 2D MRI) and 56% (vs. 2D RX) for the lateral meniscus. Conclusion 3D-MRI sizing by MeSD using the contralateral meniscus as a reconstruction template can significantly improve meniscus allograft selection. Sizing using conventional radiography should probably not be recommended. Trial registration Kantonale Ethikkommission Zürich had given the approval for the study (BASEC-No. 2018-00856).

Background: Opening-wedge high tibial osteotomy (OWHTO) has been shown to significantly increase leg length, especially in patients with large varus deformity. Thus, the current literature recommends closing-wedge high tibial osteotomy to correct malalignment in these patients to prevent postoperative leg length discrepancy. However, potential preoperative leg length discrepancy has not been considered yet. Hypothesis: It was hypothesized that patients have a decreased preoperative length of the involved leg compared with the contralateral side and that OWHTO would subsequently restore native leg length. Study Design: Case series; Level of evidence, 4. Methods: Included were 67 patients who underwent OWHTO for unilateral medial compartment knee osteoarthritis and who received full leg length assessment pre- and postoperatively. Patients with varus or valgus deformity (>3°) of the contralateral side were excluded. A musculoskeletal radiologist assessed imaging for the mechanical axis, full leg length, and tibial length of the involved and contralateral lower extremity. Statistical analysis determined the pre- and postoperative leg length discrepancy and the influence of the mechanical axis. Results: Most patients (62.7%) had a decreased length of the involved leg, with a mean preoperative mechanical axis of 5.0° ± 2.9°. Length discrepancy averaged –2.2 ± 5.8 mm, indicating a shortened involved extremity ( P = .003). OWHTO significantly increased the mean lengths of the tibia and lower limb by 3.6 ± 2.9 and 4.4 ± 4.7 mm ( P < .001), leading to a postoperative tibial and full leg length discrepancy of 2.8 ± 4.3 mm and 2.2 ± 7.3 mm ( P < .001 and P = .017, respectively). Preoperative leg length discrepancy was significantly correlated with the preoperative mechanical axis of the involved limb ( r = 0.292; P = .016), and the amount of correction was significantly associated with leg lengthening after OWHTO ( r = 0.319; P = .009). Patients with a varus deformity of ≥6.5° (n = 14) had a preoperative length discrepancy of –4.5 ± 1.6 mm ( P < .001) that was reduced to 1.8 ± 3.5 mm ( P = .08). Conclusion: Patients undergoing OWHTO have a preoperative leg length discrepancy that is directly associated with the varus deformity of the involved extremity. As OWHTO significantly increases leg length, restoration of native leg length can be achieved particularly in patients with large varus deformity.

Purpose The indication for operative treatment of displaced midshaft clavicle fractures remains controversial. However, if plate fixation is considered, implant prominence and skin irritation are the most common causes for re-operation. Low profile implants as well as closely contouring plates to the individual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracy and implant prominence of 3.5 mm pelvic reconstruction plates (PRP) with pre-contoured anatomical clavicle plates (PACP) for midshaft clavicle fractures. Methods Three-dimensional data of the largest, median and smallest male and female clavicle of an existing database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of a commercially available PACP was used for digitally positioning of the plate on the segmented clavicles. Three-dimensional printouts of each clavicle were produced and the 3.5 mm reconstruction plates were manually bent and positioned by the senior author. Computed tomography scans and three-dimensional reconstructions were then obtained to digitally compare the fitting accuracy and implant prominence. Results Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominence compared to PACP. The largest difference in implant prominence was observed in large sized female clavicles and measured 3.6 mm. Conclusion Both, the less costly PRP plates and commercially available PACP for midshaft fractures of the clavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstruction plates demonstrated reduced implant prominence with superior fitting. Hypothetically this might contribute to a reduced rate of reoperation. Level of evidence Level IV cadaveric study.

The optimal surgical treatment of complex fractures of the proximal humerus is controversial. It is proven that best results are obtained if an anatomical reduction of the fragments is achieved and, therefore, computer-assisted methods have been proposed for the reconstruction of the fractures. However, complex fractures of the proximal humerus are commonly accompanied with a relevant displacement of the fragments and, therefore, algorithms relying on the initial position of the fragments might fail. The state-of-the-art algorithm for complex fractures of the proximal humerus requires the acquisition of a CT scan of the (healthy) contralateral anatomy as a reconstruction template to address the displacement of the fragments. Pose-invariant fracture line based reconstruction algorithms have been applied successful for reassembling broken vessels in archaeology. Nevertheless, the extraction of the fracture lines and the necessary computation of their curvature are susceptible to noise and make the application of previous approaches difficult or even impossible for bone fractures close to the joints, where the cortical layer is thin. We present a novel scale-space representation of the curvature, permitting to calculate the correct alignment between bone fragments solely based on corresponding regions of the fracture lines. The fractures of the proximal humerus are automatically reconstructed based on iterative pairwise reduction of the fragments. The validation of the presented method was performed on twelve clinical cases, surgically treated after complex proximal humeral fracture, and by cadaver experiments. The accuracy of our approach was compared to the state-of-the-art algorithm for complex fractures of the proximal humerus. All reconstructions of the clinical cases resulted in an accurate approximation of the pre-traumatic anatomy. The accuracy of the reconstructed cadaver cases outperformed the current state-of-the-art algorithm.

Background The surgical treatment of malunions after midshaft clavicle fractures is associated with a number of potential complications and the surgical procedure is challenging. However, with appropriate and meticulous preoperative surgical planning, the surgical correction yields satisfactory results. The purpose of this study was to provide a guideline and detailed overview for the computer-assisted planning and 3-dimensional (3D) correction of malunions of the clavicle. Methods The 3D bone surface models of the pathologic and contralateral sides were created on the basis of computed tomography data. The computer-assisted assessment of the deformity, the preoperative plan, and the design of patient-specific guides enabling compression plating are described. Results We demonstrate the benefit and versatility of computer-assisted planning for corrective osteotomies of malunions of the midshaft clavicle. In combination with patient-specific guides and compression plating technique, the correction can be performed in a more standardized fashion. We describe the determination of the contact-optimized osteotomy plane. An osteotomy along this plane facilitates the correction and enlarges the contact between the fragments at once. We further developed a technique of a stepped osteotomy that is based on the calculation of the contact-optimized osteotomy plane. The stepped osteotomy enables the length to be restored without the need of structural bone graft. The application of the stepped osteotomy is presented for malunions of the clavicle with shortening and excessive callus formation. Conclusions The 3D preoperative planning and patient-specific guides for corrective osteotomies of the clavicle may help reduce the number of potential complications and yield results that are more predictable.

Corrective osteotomies of the forearm based on 3D computer simulation using contralateral anatomy as a reconstruction template is an approved method. Limitations are existing considerable differences between left and right forearms, and that a healthy contralateral anatomy is required. We evaluated if a computer model, not relying on the contralateral anatomy, may replace the current method by predicting the pre-traumatic healthy shape. A statistical shape model (SSM) was generated from a set of 59 CT scans of healthy forearms, encoding the normal anatomical variations. Three different configurations were simulated to predict the pre-traumatic shape with the SSM (cross-validation). In the first two, only the distal or proximal 50% of the radius were considered as pathological. In a third configuration, the entire radius was assumed to be pathological, only the ulna being intact. Corresponding experiments were performed with the ulna. Accuracy of the prediction was assessed by comparing the predicted bone with the healthy model. For the radius, mean rotation accuracy of the prediction between 2.9 ± 2.2° and 4.0 ± 3.1° in pronation/supination, 0.4 ± 0.3° and 0.6 ± 0.5° in flexion/extension, between 0.5 ± 0.3° and 0.5 ± 0.4° in radial-/ulnarduction. Mean translation accuracy along the same axes between 0.8 ± 0.7 and 1.0 ± 0.8 mm, 0.5 ± 0.4 and 0.6 ± 0.4 mm, 0.6 ± 0.4 and 0.6 ± 0.5 mm, respectively. For the ulna, mean rotation accuracy between 2.4 ± 1.9° and 4.7 ± 3.8° in pronation/supination, 0.3 ± 0.3° and 0.8 ± 0.6° in flexion/extension, 0.3 ± 0.2° and 0.7 ± 0.6° in radial-/ulnarduction. Mean translation accuracy between 0.6 ± 0.4 mm and 1.3 ± 0.9 mm, 0.4 ± 0.4 mm and 0.7 ± 0.5 mm, 0.5 ± 0.4 mm and 0.8 ± 0.6 mm, respectively. This technique provided high accuracy, and may replace the current method, if validated in clinical studies. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2630-2636, 2017.

Patellofemoral instability can be caused by tibial or femoral torsional deformity. Established surgical treatment options are rotational osteotomies, but the transfer from pre-operative planning to surgical execution can be challenging. Patient-specific instruments (PSI) are proofed to be helpful tools in realignment surgery. However, accuracy of PSI in femoral and tibial rotational osteotomies remains still unknown. Goal of the present study was to evaluate the accuracy of PSI in femoral and tibial rotational osteotomies in a patient population suffering from patellofemoral instability. All patients that underwent femoral or tibial rotational osteotomy using PSI in case of patellofemoral instability from October 2015 until April 2019 in our clinic were included. Twelve knees with twelve supracondylar femoral and seven supratuberositary tibial rotational osteotomies could be included. Accuracy of the correction was assessed using pre- and post-operative CT scans based on conventional measurements and, in 3D, based on 3D bone models of the respective patients. CT measurements revealed an absolute difference between planned and achieved rotation of 4.8° ± 3.1° for femoral and 7.9° ± 3.7° for tibial rotational osteotomies without significant difference (p = 0.069). Regarding 3D assessment, a significant difference could be observed for the residual error between femoral and tibial rotational osteotomies in the 3D angle (p = 0.014) with a higher accuracy for the femoral side. The application of PSI for femoral and tibial rotational osteotomy is a safe surgical treatment option. Accuracy for femoral rotational osteotomies is higher compared with tibial rotational osteotomies using PSI.

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.

Introduction Although treatment of bone tumors is multidisciplinary, the complete surgical resection of bone tumors remains the mainstay of the treatment. Patient-specific instruments (PSI) are personalized tools, which help the surgeon to perform tumor resections accurately. The aim of this study is to evaluate how precise the planned resection can be intraoperatively executed with the use of PSI. Patients and Methods Eleven patients who underwent a resection of bone tumor using PSI were analyzed. A preoperative model of the tumor and the affected bone was created from acquired CT scans and MRI. After defining the resection planes, PSI were produced by a 3D printer. The resected piece of bone was scanned and imported in the original planning model enabling the assessment of the distance between the planned resection plane and the realized osteotomy in every direction. Results In overall, the combined error of an osteotomy ranges from 0.74 ± 0.96 mm to 3.60 ± 2.46 mm. The average errors observed in situations with one resection plane (simple osteotomy) are lower than in complex curved osteotomies with multiple planes, in which we also found a greater variance. Conclusion 3D planned bone tumor resections using PSI show promising results for precise resection at different anatomical regions. Even if the found error range in this series is slightly higher than reported, PSI remain a valuable tool to facilitate complex bone tumor resections.

Background: The asymmetry of the medial and lateral knee compartments contributes significantly to femorotibial biomechanics and pivoting, and it is reported to be a relevant risk factor for an anterior cruciate ligament (ACL) injury. Purpose: (1) To assess the role of femoral condyle sphericity as a risk factor for an ACL rupture and rerupture. (2) To compare the new risk factor with existing bony morphological risk factors via magnetic resonance imaging (MRI) and to assess the most predictive risk factor for an ACL rupture. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective case-control study of 60 patients was conducted. Three age- and sex-matched cohorts (each n = 20) were analyzed: ACL reruptures, primary ACL ruptures, and a control group consisting of isolated meniscal tears or patients with anterior knee pain without signs of trochlear dysplasia. The lateral femoral condyle index (LFCI) as a novel MRI measurement was developed to quantify femoral sphericity. In addition, previously known MRI risk factors associated with ACL injury were analyzed (notch width index, medial tibial slope, lateral tibial slope, medial tibial depth, and lateral tibial height). Differences among groups were compared; cutoff values were defined; and diagnostic performance of the risk factors was assessed. The risk factors were subsequently analyzed with multiple logistic regression. Results: The LFCI was significantly smaller in knees with ACL reruptures (median, 0.67; range, 0.59-0.75) and primary ACL ruptures (0.67; range, 0.60-0.75) than in the control group (0.76; range, 0.6-0.81; P < .01). The LFCI yielded the highest area under the curve among the analyzed risk factors: 0.82 (95% CI, 0.7-0.9). A cutoff of 0.70 yielded a sensitivity of 78% and a specificity of 80% to predict an ACL rupture or rerupture (odds ratio, 13.79; 95% CI, 3.67-51.75). In combination with lateral tibial height (cutoff, 3.8 mm) and lateral tibial slope (cutoff, 2.9°), the diagnostic performance was improved. The area under the curve was 0.86 (95% CI, 0.75-0.94), with a sensitivity of 90% and a specificity of 70% (odds ratio, 21.00; 95% CI, 5.10-85.80). Conclusion: A decreased LFCI is associated with an ACL injury. The LFCI, lateral tibial height, and lateral tibial slope are the most predictive risk factors for an ACL injury. These findings might aid clinicians in identifying patients at risk for an ACL injury and inform the patient after reconstruction for a higher risk of rerupture.

Background Preoperative three-dimensional planning and intraoperative navigation by patient-specific instruments is a promising method for the exact correction of bone deformities. Nevertheless, disadvantages of current concepts are the missing options of adapting the surgical plan intraoperatively. By providing the surgeons with a controlled length adjustment through the patient-specific instruments, the application area can usefully be expanded in the treatment of clavicle osteosyntheses. Methods In three cases, preoperative three-dimensional surgical planning with the intraoperative use of patient-specific instruments was applied. The computer-assisted assessments of clavicle deformities, the preoperative plan, and the design of patient-specific instruments were created on the basis of computed tomography data. Reduction guides for restoring length and rotation according to the mirrored healthy contralateral side were enhanced with adaptable length adjustment functions. The screw thread of the reduction guides enabled temporary distraction of the clavicle fracture fragments and a controlled compression of the optionally used interposed bone block between clavicle fragments. Results Navigated clavicle osteosyntheses by enhanced patient-specific instruments was executed uneventful in all three cases. The surgeon was able to adapt clavicle length in a planned axis intraoperatively as clinically desired. Conclusion Computer-assisted planning of clavicle osteosynthesis and surgical navigation with additional adaptable patient-specific instruments can usefully expand the previous application areas. By using guided length adjustments, the fragments and optionally the graft can be compressed along a planned axis as desired to ensure optimal bone healing. Level of evidence Basic science study, Surgical technique Electronic supplementary material The online version of this article (10.1186/s13018-019-1151-8) contains supplementary material, which is available to authorized users.

3D computer-assisted corrective osteotomy has become the state-of-the-art for surgical treatment of complex bone deformities. Despite available technologies, the automatic generation of clinically acceptable, ready-to-use preoperative planning solutions is currently not possible for such pathologies. Multiple contradicting and mutually dependent objectives have to be considered, as well as clinical and technical constraints, generally requiring iterative manual adjustments. This leads to unnecessary efforts and unbearable clinical costs, hindering also the quality of patient treatment. In this paper, we propose an optimization framework for the generation of ready-to-use preoperative planning solutions in a fully automatic fashion. An automatic diagnostic assessment using patient-specific 3D models is performed for 3D malunion quantification and definition of the optimization parameters. Afterward, clinical objectives are translated into the optimization module, and controlled through tailored fitness functions based on a weighted and multi-staged optimization approach. The optimization is based on a genetic algorithm capable of solving multi-objective optimization problems with non-linear constraints. The framework outputs a complete preoperative planning solution including position and orientation of the osteotomy plane, transformation to achieve the bone reduction, and position and orientation of the fixation plate and screws. A qualitative validation was performed on 36 consecutive cases of radius osteotomy where solutions generated by the optimization algorithm (OA) were compared against the gold standard (GS) solutions generated by experienced surgeons. Solutions were blinded and presented to 6 readers, who voted OA solutions to be better in 55% of the time. The quantitative evaluation was based on different error measurements, showing average improvements with respect to the GS., Comment: 37 pages, 15 figures, submitted to Medical Image Analysis Journal

We present a method for automatically determining the position and orientation of the articular marginal plane (AMP) of the proximal humerus in computed tomography (CT) images without segmentation or hand-crafted features. The process is broken down into 3 stages. Stage 1 determines a coarse estimation of the AMP center by sampling patches over the entire image and combining predictions with a novel kernel density estimation method. Stage 2 utilizes the estimate from stage 1 to focus on a smaller sampling region and operates at a higher images resolution to obtain a refined prediction of the AMP center. Stage 3 focuses patch sampling on the region around the center obtained at stage 2 and regresses the tip of a vector normal to the AMP which yields the orientation of the plane. The system was trained and evaluated on 27 upper arm CTs. In a 4-fold cross-validation the mean error in estimating the AMP center was \(1.30\,{\pm }\,0.65\) mm and the angular error for estimating the normal vector was \(4.68\,{\pm }\,2.84^\circ \).

The contralateral anatomy is regularly used as a reconstruction template for corrective osteotomies of several deformities and pathological conditions. However, there is lack of evidence that the intra-individual differences between both tibiae are sufficiently small to use the contralateral tibia as a 3D reconstruction template for complex osteotomies. The aim of this study was to evaluate the intra-individual side differences of the tibia in length, torsion, angulation, and translation using 3D measurement techniques. 3D surface models of both tibiae were created from computed tomography data of 51 cadavers. The (mirrored) models of the right tibiae were divided into two halves at the centre of the shaft. Thereafter, the proximal and distal segments were aligned to the left (contralateral) tibia in an automated fashion. The relative 3D transformation between both aligned segments was measured to quantify the side difference in 6° of freedom (3D translation vector, 3 angles of rotation). The mean side difference in tibia length was 2.1 mm (SD 1.3 mm; range 0.2–5.9 mm). The mean side difference in torsion was 4.9° (SD 4.1°; range 0.2°–17.6°). The mean side difference in the coronal and sagittal planes was 1.1° (SD 0.9°; range 0.0°–4.6°) and 1.0° (SD 0.8°; range 0.1°–2.9°), respectively. The present study confirms small side differences in torsion between the left and right tibia, while the side differences in the coronal and sagittal plane are probably negligible. The contralateral tibia seems to be a reliable reconstruction template for the 3D preoperative planning of complex corrective osteotomies of the tibia. However, torsional differences should be interpreted with caution, as a single cut-off value of a clinically relevant torsional side difference cannot be defined. The presented results are relevant to surgeons considering the contralateral tibia as a 3D reconstruction template for corrective osteotomies of the tibia. Basic science.

Background In the presence of severe osteoarthritis, osteonecrosis, or proximal humeral fracture, the contralateral humerus may serve as a template for the 3-dimensional (3D) preoperative planning of reconstructive surgery. The purpose of this study was to develop algorithms for performing 3D measurements of the humeral anatomy and further to assess side-to-side (bilateral) differences in humeral head retrotorsion, humeral head inclination, humeral length, and humeral head radius and height. Methods The 3D models of 140 paired humeri (70 cadavers) were extracted from computed tomographic data. Geometric characteristics quantifying the humeral anatomy in 3D were determined in a semiautomatic fashion using the developed computer algorithms. The results between the sides were compared for evaluating bilateral differences. Results The mean bilateral difference of the humeral retrotorsion angle was 6.7° (standard deviation [SD], 5.7°; range, −15.1° to 24.0°; P = .063); the mean side difference of the humeral head inclination angle was 2.3° (SD, 1.8°; range, −5.1° to 8.4°; P = .12). The side difference in humeral length (mean, 2.9 mm; SD, 2.5 mm; range, −8.7 mm to 10.1 mm; P = .04) was significant. The mean side difference in the head sphere radius was 0.5 mm (SD, 0.6 mm; range, −3.2 mm to 2.2 mm; P = .76), and the mean side difference in humeral head height was 0.8 mm (SD, 0.6 mm; range, −2.4 mm to 2.4 mm; P = .44). Conclusions The contralateral anatomy may serve as a reliable reconstruction template for humeral length, humeral head radius, and humeral head height if it is analyzed with 3D algorithms. In contrast, determining humeral head retrotorsion and humeral head inclination from the contralateral anatomy may be more prone to error.

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. 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). 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. 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. III.

Background Opening-wedge osteotomies of the distal radius, performed with three-dimensional printed patient-specific instruments, are a promising technique for accurate correction of malunions. Nevertheless, reports of residual malalignments and discrepancies in the plate and screw position from the planned fixation exist. Consequently, we developed a patient-specific ramp-guide technique, combining navigation of plate positioning, osteotomy cutting, and reduction. The aim of this study is to compare the accuracy of navigation of three-dimensional planned opening-wedge osteotomies, using a ramp-guide, over state-of-the-art guide techniques relying solely on pre-drilled holes. Methods A retrospective analysis was carried out on opening-wedge osteotomies of the distal radius, performed between May 2016 and April 2017, with patient-specific instruments. Eight patients were identified in which a ramp-guide for the distal plate fixation was used. We compared the reduction accuracy with a control group of seven patients, where the reduction was performed with pre-drilled screw holes placed with the patient-specific instruments. The navigation accuracy was assessed by comparing the preoperative plans with the postoperative segmented, computed tomography scans. The accuracy was expressed using a 3D angle and in measurements of all six degrees of freedom (3 translations, 3 rotations), with respect to an anatomical coordinate system. Results The duration of the surgery of the ramp-guide group was significantly shorter compared to the control group. Significantly less rotational and translational residual malalignment error was observed in the open-wedged osteotomies, where patient-specific instruments with ramp-guides were used. On average, a residual rotational malalignment error of 2.0° (± 2.2°) and a translational malalignment error of 0.6 mm (± 0.2 mm) was observed in the ramp-guide group, as compared to the 4.2° (± 15.0°) and 1.0 mm (± 0.4 mm) error in the control group. The used plate was not significantly positioned more accurately, but significantly fewer screws (15.6%) were misaligned in the distal fragment compared to the control group (51.9%). Conclusion The use of the presented ramp-guide technique in opening-wedge osteotomies is improving reduction accuracy, screw position, and surgical duration, compared to the existing patient-specific instrument based navigation methods.

The accurate restoration of premorbid anatomy is key for the success of reconstructive surgeries of the proximal part of the humerus. The bicipital groove has been proposed as a landmark for the prediction of humeral head retrotorsion. We hypothesized that a novel method based on bilateral registration of the bicipital groove yields an accurate approximation of the premorbid anatomy of the proximal part of the humerus.Three-dimensional (3D) triangular surface models were created from computed tomographic data of 100 paired humeri (50 cadavers). Segments of the distal part of the humerus and the humeral shaft of prespecified lengths were defined. A surface registration algorithm was applied to superimpose the models onto the mirrored contralateral humeral model based on the defined segments. We evaluated the 3D proximal humeral contralateral registration (p-HCR) errors, defined as the difference in 3D rotation of the humeral head between the models when superimposed. For comparison, we quantified the landmark-based retrotorsion (LBR) error, defined as the intra-individual difference in retrotorsion, measured with a landmark-based 3D method.The mean 3D p-HCR error using the most proximal humeral shaft (bicipital groove) segment for the registration was 2.8° (standard deviation [SD], 1.5°; range, 0.6° to 7.4°). The mean LBR error of the reference method was 6.4° (SD, 5.9°; range, 0.5° to 24.0°).Bilateral 3D registration of the bicipital groove is a reliable method for approximating the premorbid anatomy of the proximal part of the humerus.The accurate approximation of the premorbid anatomy is a key for the successful restoration of the premorbid anatomy of the proximal part of the humerus.

BACKGROUND In computer-assisted reconstructive surgeries, the contralateral anatomy is established as the best available reconstruction template. However, existing intra-individual bilateral differences or a pathological, contralateral humerus may limit the applicability of the method. The aim of the study was to evaluate whether a statistical shape model (SSM) has the potential to predict accurately the pretraumatic anatomy of the humerus from the posttraumatic condition. METHODS Three-dimensional (3D) triangular surface models were extracted from the computed tomographic data of 100 paired cadaveric humeri without a pathological condition. An SSM was constructed, encoding the characteristic shape variations among the individuals. To predict the patient-specific anatomy of the proximal (or distal) part of the humerus with the SSM, we generated segments of the humerus of predefined length excluding the part to predict. The proximal and distal humeral prediction (p-HP and d-HP) errors, defined as the deviation of the predicted (bone) model from the original (bone) model, were evaluated. For comparison with the state-of-the-art technique, i.e., the contralateral registration method, we used the same segments of the humerus to evaluate whether the SSM or the contralateral anatomy yields a more accurate reconstruction template. RESULTS The p-HP error (mean and standard deviation, 3.8° ± 1.9°) using 85% of the distal end of the humerus to predict the proximal humeral anatomy was significantly smaller (p = 0.001) compared with the contralateral registration method. The difference between the d-HP error (mean, 5.5° ± 2.9°), using 85% of the proximal part of the humerus to predict the distal humeral anatomy, and the contralateral registration method was not significant (p = 0.61). The restoration of the humeral length was not significantly different between the SSM and the contralateral registration method. CONCLUSIONS SSMs accurately predict the patient-specific anatomy of the proximal and distal aspects of the humerus. The prediction errors of the SSM depend on the size of the healthy part of the humerus. CLINICAL RELEVANCE The prediction of the patient-specific anatomy of the humerus is of fundamental importance for computer-assisted reconstructive surgeries.

BACKGROUND: With current 3-dimensional (3D) computer-based methods for the assessment of deformities, a surface registration method is applied to superimpose a computer model of the pathological bone onto a mirrored computer model of the contralateral side. However, because of bilateral differences, especially in humeral torsion, such template-based approaches may introduce bias in the assessment of a distal humeral deformity. We hypothesized that a novel registration approach might prove superior to the current approach in reducing such bias, thus yielding improved accuracy of 3D assessment of distal humeral deformities. METHODS: Three-dimensional triangular surface models were generated from computed tomographic (CT) data of 100 paired humeri without a pathological condition. Humeral segments of varying, predetermined lengths, excluding the distal part of the humerus, were defined. A surface registration algorithm was applied to superimpose the humeral models of both sides based on each selected segment. Humeral contralateral registration (HCR) errors, defined as the residual differences in apparent 3D orientation between the distal parts, were evaluated. RESULTS: The mean HCR error (and standard deviation) using the distal-most humeral shaft segment to assess the angular orientation was 2.3° ± 1.1 (range, 0.5° to 5.8°). Including the humeral head in the surface registration algorithm, however, as is done currently, resulted in a higher HCR error (p 10° in 20% of the cases and between 5° and 10° in an additional 50% of the cases. By comparison, using the proposed distal-most humeral shaft segment, the HCR error was between 5° and 10° in only 2% of cases, and was never >10°. The proximal segments are nevertheless used in the proposed method for registering humeral length. CONCLUSIONS: The proposed new approach yields a deformity assessment that is less prone to bias arising from inherent bilateral differences and therefore is more accurate than current surface registration approaches. CLINICAL RELEVANCE: Accurate 3D assessment is of fundamental importance if computer-based methods are applied in the correction of posttraumatic deformities.

The purpose of this article is to determine the osseous morphology of snapping scapulae on CT images.Retrospectively, 2D and 3D CT images of the scapulae of 35 patients with snapping scapula were compared with 35 age-matched control group subjects. Two observers analyzed the following parameters: presence of the Luschka tubercle; abnormalities of the bones and periscapular soft tissues; shape, thickness, and length of the superior angle of the scapula; craniocaudal length of the scapula; minimum distance between the scapula and rib cage; depth of the subscapular fossa; and the superomedial angle.In patients with snapping scapulae, observer 1 did not find any Luschka tubercles, whereas observer 2 detected one; in the control group both observers found two Luschka tubercles (p0.49). One scapular osteochondroma was found in the group with snapping scapulae. No further abnormalities of the rib cage or periscapular soft tissues were found in that group. The superior angle of the scapula was significantly thicker in the snapping scapula group compared with the control group (4.8 ± 1.3 mm vs 4.0 ± 1.0 mm, p0.012). The subscapular fossa was significantly deeper in patients with snapping scapula than in control group subjects (25.7 ± 5.2 mm vs 21.8 ± 5.0 mm, p0.005). The remaining parameters did not differ significantly between the groups.The Luschka tubercle was rarely observed and not associated with a snapping scapula. However, the superior angle of the scapula was significantly thicker and the subscapular fossa was significantly deeper in patients with snapping scapula than in control group subjects.

Three-dimensional computer-assisted preoperative planning, combined with patient-specific surgical guides, has become an effective technique for treating complex extra- and intraarticular bone malunions by corrective osteotomy. The feasibility and accuracy of such a technique has not yet been evaluated for ankle deformities. Four surgical cases of varying complexity and location were selected for evaluation. Three-dimensional bone models of the affected and contralateral healthy lower limb were generated from computed tomography scans. The preoperative planning software permitted quantification of the deformity in 3 dimensions and subsequent simulation of reduction, yielding a precise surgical plan. Patient-specific surgical guides were designed, manufactured, and finally applied during surgery to reproduce the preoperative plan. Evaluation of the postoperative computed tomography scans indicated adequate reduction accuracy with residual translational and rotational errors of

Purpose To simulate the most isometric insertion points of the anterolateral ligament (ALL) in a weight-bearing 3-dimensional computed tomography (CT) model using previously published anatomic landmarks and to define radiographic landmarks, which make for an easier identification of the optimal insertion points. Methods The most isometric femoral insertion points were analyzed for 10 individuals, using data of weight-bearing CT scans in increasing knee flexion positions. An automatic string generation algorithm helped identify isometrically optimal points using an isometric score (0 indicating optimal isometry). Subsequently, a general femoral insertion point was determined, which preserved the isometry in all tested individuals. Based on the femoral insertion point, we assessed the influence of varying tibial insertion points on the isometric behavior of the ALL. Results The defined femoral insertion point, which preserved the isometry in all analyzed individuals, had a median isometric score between 0.167 × 10 −3 and 0.559 × 10 −3 . The average distance from the most prominent point of the lateral epicondyle was 9.7 mm (standard deviation [SD], 1.6) in a straight superior direction. In a straight lateral radiographic view, this point is located exactly at the intersection of a tangent set between the posterior cortex of the femur and a second perpendicular line intersecting at the level of the most (superior-) posterior point of the Blumensaat line. The best isometric behavior was found on the anatomically defined mean tibial insertion point, located at 37% of the width of the tibial plateau, which worsened gradually if corrected to anterior or posterior. Conclusions We determined femoral and tibial insertion points as well as radiographic landmarks for the reconstruction of the ALL that are based on published anatomic descriptions and preserve isometry in all analyzed individuals in this study. Clinical Relevance This study provides new information, which might be helpful to define isometrically optimal insertion points for ALL reconstruction.

Background Sarcomas are associated with a relatively high local recurrence rate of around 30 % in the pelvis. Inadequate surgical margins are the most important reason. However, obtaining adequate margins is particularly difficult in this anatomically demanding region. Recently, three-dimensional (3-D) planning, printed models, and patient-specific instruments (PSI) with cutting blocks have been introduced to improve the precision during surgical tumor resection. This case series illustrates these modern 3-D tools in pelvic tumor surgery. Methods The first consecutive patients with 3-D-planned tumor resection around the pelvis were included in this retrospective study at a University Hospital in 2015. Detailed information about the clinical presentation, imaging techniques, preoperative planning, intraoperative surgical procedures, and postoperative evaluation is provided for each case. The primary outcome was tumor-free resection margins as assessed by a postoperative computed tomography (CT) scan of the specimen. The secondary outcomes were precision of preoperative planning and complications. Results Four patients with pelvic sarcomas were included in this study. The mean follow-up was 7.8 (range, 6.0–9.0) months. The combined use of preoperative planning with 3-D techniques, 3-D-printed models, and PSI for osteotomies led to higher precision (maximal (max) error of 0.4 centimeters (cm)) than conventional 3-D planning and freehand osteotomies (max error of 2.8 cm). Tumor-free margins were obtained where measurable (n = 3; margins were not assessable in a patient with curettage). Two insufficiency fractures were noted postoperatively. Conclusions Three-dimensional planning as well as the intraoperative use of 3-D-printed models and PSI are valuable for complex sarcoma resection at the pelvis. Three-dimensionally printed models of the patient anatomy may help visualization and precision. PSI with cutting blocks help perform very precise osteotomies for adequate resection margins.

Corrective osteotomies of the forearm based on 3D computer simulation using contralateral anatomy as a reconstruction template is an approved method. Limitations are existing considerable differences between left and right forearms, and that a healthy contralateral anatomy is required. We evaluated if a computer model, not relying on the contralateral anatomy, may replace the current method by predicting the pre-traumatic healthy shape. A statistical shape model (SSM) was generated from a set of 59 CT scans of healthy forearms, encoding the normal anatomical variations. Three different configurations were simulated to predict the pre-traumatic shape with the SSM (cross-validation). In the first two, only the distal or proximal 50% of the radius were considered as pathological. In a third configuration, the entire radius was assumed to be pathological, only the ulna being intact. Corresponding experiments were performed with the ulna. Accuracy of the prediction was assessed by comparing the predicted bone with the healthy model. For the radius, mean rotation accuracy of the prediction between 2.9 ± 2.2° and 4.0 ± 3.1° in pronation/supination, 0.4 ± 0.3° and 0.6 ± 0.5° in flexion/extension, between 0.5 ± 0.3° and 0.5 ± 0.4° in radial-/ulnarduction. Mean translation accuracy along the same axes between 0.8 ± 0.7 and 1.0 ± 0.8 mm, 0.5 ± 0.4 and 0.6 ± 0.4 mm, 0.6 ± 0.4 and 0.6 ± 0.5 mm, respectively. For the ulna, mean rotation accuracy between 2.4 ± 1.9° and 4.7 ± 3.8° in pronation/supination, 0.3 ± 0.3° and 0.8 ± 0.6° in flexion/extension, 0.3 ± 0.2° and 0.7 ± 0.6° in radial-/ulnarduction. Mean translation accuracy between 0.6 ± 0.4 mm and 1.3 ± 0.9 mm, 0.4 ± 0.4 mm and 0.7 ± 0.5 mm, 0.5 ± 0.4 mm and 0.8 ± 0.6 mm, respectively. This technique provided high accuracy, and may replace the current method, if validated in clinical studies. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2630-2636, 2017.

Background Corrective osteotomies of malunited fractures of the proximal and distal humerus are among the most demanding orthopedic procedures. Whereas the restoration of the normal humeral anatomy is the ultimate goal, the quantification of the deformity as well as the transfer of the preoperative plan is challenging. The purpose of this study was to provide a guideline for 3-dimensional (3D) corrective osteotomies of malunited intra-articular fractures of the humerus and a detailed overview of existing and novel instruments to enlarge the toolkit for 3D preoperative planning and intraoperative realization using patient-specific guides. Methods We describe the preoperative 3D deformity analysis, relevant considerations for the preoperative plan, design of the patient-specific guides, and surgical technique of corrective osteotomies of the humerus. Results The presented technique demonstrates the benefit of computer-assisted surgery for complex osteotomies of the humerus from a preoperative deformity analysis to the creation of feasible surgical procedures and the generation of patient-specific guides. Conclusions A 3D analysis of a post-traumatic deformity of the humerus, 3D preoperative planning, and use of patient-specific guides facilitate corrective osteotomies of complex malunited humeral fractures.

Opening-wedge osteotomies of the distal radius, performed with three-dimensional printed patient-specific instruments, are a promising technique for accurate correction of malunions. Nevertheless, reports of residual malalignments and discrepancies in the plate and screw position from the planned fixation exist. Consequently, we developed a patient-specific ramp-guide technique, combining navigation of plate positioning, osteotomy cutting, and reduction. The aim of this study is to compare the accuracy of navigation of three-dimensional planned opening-wedge osteotomies, using a ramp-guide, over state-of-the-art guide techniques relying solely on pre-drilled holes.A retrospective analysis was carried out on opening-wedge osteotomies of the distal radius, performed between May 2016 and April 2017, with patient-specific instruments. Eight patients were identified in which a ramp-guide for the distal plate fixation was used. We compared the reduction accuracy with a control group of seven patients, where the reduction was performed with pre-drilled screw holes placed with the patient-specific instruments. The navigation accuracy was assessed by comparing the preoperative plans with the postoperative segmented, computed tomography scans. The accuracy was expressed using a 3D angle and in measurements of all six degrees of freedom (3 translations, 3 rotations), with respect to an anatomical coordinate system.The duration of the surgery of the ramp-guide group was significantly shorter compared to the control group. Significantly less rotational and translational residual malalignment error was observed in the open-wedged osteotomies, where patient-specific instruments with ramp-guides were used. On average, a residual rotational malalignment error of 2.0° (± 2.2°) and a translational malalignment error of 0.6 mm (± 0.2 mm) was observed in the ramp-guide group, as compared to the 4.2° (± 15.0°) and 1.0 mm (± 0.4 mm) error in the control group. The used plate was not significantly positioned more accurately, but significantly fewer screws (15.6%) were misaligned in the distal fragment compared to the control group (51.9%).The use of the presented ramp-guide technique in opening-wedge osteotomies is improving reduction accuracy, screw position, and surgical duration, compared to the existing patient-specific instrument based navigation methods.

Purpose The indication for operative treatment of displaced midshaft clavicle fractures remains controversial. However, if plate fixation is considered, implant prominence and skin irritation are the most common causes for re-operation. Low profile implants as well as closely contouring plates to the individual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracy and implant prominence of 3.5 mm pelvic reconstruction plates (PRP) with pre-contoured anatomical clavicle plates (PACP) for midshaft clavicle fractures. Methods Three-dimensional data of the largest, median and smallest male and female clavicle of an existing database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of a commercially available PACP was used for digitally positioning of the plate on the segmented clavicles. Three-dimensional printouts of each clavicle were produced and the 3.5 mm reconstruction plates were manually bent and positioned by the senior author. Computed tomography scans and three-dimensional reconstructions were then obtained to digitally compare the fitting accuracy and implant prominence. Results Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominence compared to PACP. The largest difference in implant prominence was observed in large sized female clavicles and measured 3.6 mm. Conclusion Both, the less costly PRP plates and commercially available PACP for midshaft fractures of the clavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstruction plates demonstrated reduced implant prominence with superior fitting. Hypothetically, this might contribute to a reduced rate of reoperation. Level of evidence Level IV cadaveric study.

Congenital or posttraumatic bone deformity may lead to reduced range of motion, joint instability, pain, and osteoarthritis. The conventional joint-preserving therapy for such deformities is corrective osteotomy—the anatomical reduction or realignment of bones with fixation. In this procedure, the bone is cut and its fragments are correctly realigned and stabilized with an implant to secure their position during bone healing. Corrective osteotomy is an elective procedure scheduled in advance, providing sufficient time for careful diagnosis and operation planning. Accordingly, computer-based methods have become very popular for its preoperative planning. These methods can improve precision not only by enabling the surgeon to quantify deformities and to simulate the intervention preoperatively in three dimensions, but also by generating a surgical plan of the required correction. However, generation of complex surgical plans is still a major challenge, requiring sophisticated techniques and profound clinical expertise. In addition to preoperative planning, computer-based approaches can also be used to support surgeons during the course of interventions. In particular, since recent advances in additive manufacturing technology have enabled cost-effective production of patient- and intervention-specific osteotomy instruments, customized interventions can thus be planned for and performed using such instruments. In this chapter, state of the art and future perspectives of computer-assisted deformity-correction surgery of the upper and lower extremities are presented. We elaborate on the benefits and pitfalls of different approaches based on our own experience in treating over 150 patients with three-dimensional preoperative planning and patient-specific instrumentation.

The accurate reduction of tibial plateau malunions can be challenging without guidance. In this work, we report on a novel technique that combines 3-dimensional computer-assisted planning with patient-specific surgical guides for improving reliability and accuracy of complex intraarticular corrective osteotomies. Preoperative planning based on 3-dimensional bone models was performed to simulate fragment mobilization and reduction in 3 cases. Surgical implementation of the preoperative plan using patient-specific cutting and reduction guides was evaluated; benefits and limitations of the approach were identified and discussed. The preliminary results are encouraging and show that complex, intraarticular corrective osteotomies can be accurately performed with this technique. For selective patients with complex malunions around the tibia plateau, this method might be an attractive option, with the potential to facilitate achieving the most accurate correction possible.

Purpose To present results regarding the accuracy of the reduction of surgically reconstructed scaphoid nonunions or fractures using 3-dimensional computer-based planning with and without patient-specific guides. Methods Computer-based surgical planning was performed with computed tomography (CT) data on 22 patients comparing models of the pathological and the opposite uninjured scaphoid in 3 dimensions. For group 1 (9 patients), patient-specific guides were designed and manufactured using additive manufacturing technology. During surgery, the guides were used to define the orientation of the reduced fragments. The scaphoids in group 2 (13 patients) were reduced with the conventional freehand technique. All scaphoids in both groups were fixed with a headless compression screw or K-wires, and all bone defects (except one) were filled with autologous bone grafts or vascularized grafts. Postoperative CT scans were acquired 2 or more months after the operations to monitor consolidation and compare the final result with the preoperative plan. The clinical results and accuracy of the reconstructions were compared. Results In group 1, 8 of 9 scaphoids healed after 2 to 6 months, and partial nonunion after 9 months was observed in one patient. In group 2, 11 of 13 scaphoids healed between 2 and 34 months whereas 2 scaphoids did not consolidate. Comparison of the preoperative and postoperative 3-dimensional data revealed an average residual displacement of 7° (4° in flexion-extension, 4° in ulnar-radial deviation, and 3° in pronation-supination) in group 1. In group 2, residual displacement after surgery was 26° (22° in flexion-extension, 12° in ulnar-radial deviation, and 7° in pronation-supination). The difference in the accuracy of reconstruction was significant. Conclusions Although the scaphoid is small, patient-specific guides can be used to perform scaphoid reconstructions. When the guides were used, the reconstructions were significantly more anatomic compared with those resulting from the freehand technique. Type of study/level of evidence Therapeutic III.

In shoulder arthroplasty, the proximal humeral head is resected by sawing along the cartilage-bone transition and replaced by a prosthetic implant. The resection plane, called articular margin plane (AMP), defines the orientation, position and size of the prosthetic humeral head in relation to the humeral shaft. Therefore, the correct definition of the AMP is crucial for the computer-assisted preoperative planning of shoulder arthroplasty. We present a fully automated method for estimating the AMP relying only on computed tomography (CT) images of the upper arm. It consists of two consecutive steps, each of which uses random regression forests (RFs) to establish a direct mapping from the CT image to the AMP parameters. In the first step, image intensities serve as features to compute a coarse estimate of the AMP. The second step builds upon this estimate, calculating a refined AMP using novel feature types that combine a bone enhancing sheetness measure with ray features. The proposed method was evaluated on a dataset consisting of 72 CT images of upper arm cadavers. A mean localization error of 2.40mm and a mean angular error of 6.51° was measured compared to manually annotated ground truth.

Purpose To investigate the reduction accuracy of 3-dimensional planned single-cut osteotomies (SCOTs) of the forearm that were performed using patient-specific guides. Methods A retrospective analysis of SCOTs performed between 2012 and 2014 was performed. Ten patients (age, 15–59 years) with 6 malunions of the ulna and 6 malunions of the radius were identified. The reduction accuracy was assessed by comparing the 3-dimensional preoperative plan of each osteotomy with the superimposed bone model extracted from postoperative computed tomography data. The difference was assessed by 3-dimensional angle and in all 6 degrees of freedom (3 translations, 3 rotations) with respect to an anatomical coordinate system. Wrist range of motion and grip strength was assessed after a mean of 16.7 months and compared with the preoperative measurements. Results On average, the 12 SCOTs demonstrated excellent accuracy of the reduction with respect to rotation (ie, pronation/supination, 4.9°; flexion/extension, 1.7°; ulnar/radial angulation, 2.0°) and translation (ie, proximal/distal, 0.8 mm; radial/ulnar, 0.8 mm; dorsal/palmar, 0.8 mm). A mean residual 3-dimensional angle of 5.8° (SD, 3.6°) was measured after surgery. All 6 patients operated on for reasons of a reduced range of motion demonstrated improved symptoms and increased movement (from 20° to 80°). In the patients with unstable/painful distal radioulnar joint, 3 were totally free of complaints and 1 patient showed residual pain during sports. Conclusions A SCOT combined with patient-specific guides is an accurate and reliable technique to restore normal anatomy in multiplanar deformities of the forearm. Type of study/level of evidence Therapeutic IV.

Background Prophylactic fixation of the contralateral hip in cases of slipped upper femoral epiphysis is controversial. Therefore, using a single-cannulated screw has been widely accepted. However, differing reports exist on the occurrence of persisting growth after prophylactic epiphysiodesis. The aim of this retrospective study was to evaluate the presence of persisting growth of the upper femoral epiphysis after prophylactic fixation. Methods From 2006 until 2009, 11 children underwent prophylactic pinning using a single-cannulated 6.5-mm cancellous screw. Time to fusion, persisting growth, and overgrowing of the screw were measured on plain radiographs taken postoperatively and at least after the growth plate was fused. Results All patients except 1 (91%) showed a persisting growth of the epiphysis, and in 2 cases a hardware replacement was necessary. The mean increase of the femoral neck length was 8.2% (SEM 1.46%). Mean follow-up was 37 months (range, 12 to 49 mo). All patients had a Risser sign grade 0 at the time of surgery, and equal or less than grade 3, when the growth plate was fused. Conclusions Despite previous reports that a prophylactic fixation using a single-cannulated cancellous screw is unproblematic and safe, we showed that in our series growth persistence was the rule and in some cases the physeal overgrowth necessitates a hardware replacement. Careful follow-up until fusion of the growth plate should be recommended.

Purpose To quantify the strength of suture fixation of knotless suture anchors in relation to the anchors' pullout strength and to compare these results with the static friction between different sutures and anchor materials. Methods Suture slippage within the anchor and pullout strength of 4 different knotless suture anchor models were assessed in a bovine bone model. Furthermore, the peak force before onset of slippage of different sutures trapped between increasingly loaded 4-mm rods made of commonly used anchor material (polyetheretherketone, poly-L-lactide acid, metal) was assessed. Results In all but 1 of the tested anchors, there was a relevantly lower load needed for slippage of the sutures than to pull out the anchor from bone. The mean load to anchor pullout ranged between 156 and 269 N. The load to suture slippage ranged between 66 and 109 N. All sutures were better held between the metal rods (mean, 21; 95% confidence interval [CI], 19.2 to 23.3) than with polyetheretherketone rods (mean, 17; 95% CI, 15.7 to 18.1) or poly-L-lactide acid rods (mean, 18; 95% CI, 17.6 to 18.4). Conclusions In the case of suture anchors that hold the sutures by clamping, the hold of the suture in the anchor may be far lower than the pullout strength of the anchor from bone, because the sutures just slip out from the anchor through the clamping mechanism. This is well explained by the low static friction achieved between the tested sutures and the test rods made of anchor materials. Clinical Relevance The use of knotless suture anchors appears quick and easy to perform; however, most of the anchor systems could not even reach half of the anchor pullout strength from bone before suture slippage occurred.

The objective of our study was to investigate a possible role of pathogenic mutations in the growth factor genes insulin like growth factor I (IGF-I) and placental growth factor (PlGF) and their receptors IGF-IR and fms-like tyrosine kinase 1 (Flt1) in the pathogenesis of placental dysfunction.We analyzed two patient groups with IUGR (intrauterine growth restriction), 18 mother-child pairs with absent or reversed enddiastolic flow (ARED) in the umbilical artery and 12 mother-child pairs with preserved enddiastolic flow (PED) in the presence of a bilateral abnormal uterine artery Doppler waveform (Notching). The control group comprised of 50 healthy mother-child pairs.Sequencing did not show a pathogenic mutation in any of the analyzed genes. However, we detected three novel polymorphisms in the IGF-IR gene. In addition, we identified one unknown polymorphism in exon 1 of the non-coding region of PlGF and 2 novel variants in exons 1 and 6 of Flt1.In summary, our results do not provide evidence for a relevant role of pathogenic mutations in the genes IGF-I, IGF-IR, PlGF, and Flt1 in the etiology of IUGR with ARED or PED flow.

Background: Computer assisted corrective osteotomy of the diaphyseal forearm and the distal radius based on computer simulation and patient-specific guides has been described as a promising technique for accurate reconstruction of forearm deformities. Thereby, the intraoperative use of patient-specific drill and cutting guides facilitate the transfer of the preoperative plan to the surgery. However, the difference between planned and performed reduction is difficult to assess with conventional radiographs. The aim of this study was to evaluate the accuracy of this surgical technique based on postoperative three-dimensional (3D) computed tomography (CT) data. Methods: Fourteen patients (mean age 23.2 (range, 12-58) years) with an extra-articular deformity of the forearm had undergone computer assisted corrective osteotomy with the healthy anatomy of the contralateral uninjured side as a reconstruction template. 3D bone surface models of the pathological and contralateral side were created from CT data for the computer simulation. Patient-specific drill and cutting guides including the preoperative planned screw direction of the angular-stable locking plates and the osteotomy planes were used for the intraoperative realization of the preoperative plan. There were seven opening wedge osteotomies and nine closing wedge (or single-cut) osteotomies performed. Eight-ten weeks postoperatively CT scans were obtained to assess bony consolidation and additionally used to generate a 3D model of the forearm. The simulated osteotomies- preoperative bone models with simulated correction -a nd the performed osteotomies - postoperative bone models – were analyzed for residual differences in 3D alignment. Results: On average, a significant higher residual rotational deformity was observed in opening wedge osteotomies (8.30° ± 5.35°) compared to closing wedge osteotomies (3.47° ± 1.09°). The average residual translation was comparable small in both groups, i.e., below 1.5 mm and 1.1 mm for opening and closing wedge osteotomies, respectively. Conclusions: The technique demonstrated high accuracy in performing closing wedge (or single-cut) osteotomies. However, for opening wedge osteotomies with extensive lengthening, probably due to the fact that precise reduction was difficult to achieve or maintain, the final corrections were less accurate.