Correction of severe wrist deformity following physeal arrest of the distal radius with the aid of a three-dimensional computer simulation

Calcium phosphate bone cement and metaphyseal -corrective osteotomies in the upper extremity: long-term follow-up of 10 children

BACKGROUND AND PURPOSE

The evaluation of metaphyseal angular deformities in children includes indication and timing for corrective osteotomy, and possible need for several operations during growth. Gap-fillers are usually autologous bone grafts, which might cause donor site problems. Calcium phosphate (CaP) bone cement may be a possible alternative.

PATIENTS AND METHODS

We performed 15 corrective osteotomies from 2007 to 2013 in 10 children, ages 5 to 18, with Norian SRS bone cement as a gap-filler, in the distal radius (12), proximal radius (1), and proximal humerus (2). Due to growth arrest and gradually increasing malalignments 3/10 children needed 1-3 additional corrections. Locking plates and screws were used except in 1 case at first surgery, aged 5 (K-wires). 2 children needed additional limb lengthening with external fixator.

RESULTS

All osteotomies healed. Postoperative radiographs and CT scans showed good alignment and gradual transformation of cement into bone. Remodeling was visible intraoperatively in patients needing multiple surgeries. Return to earlier osteotomy sites was unproblematic. No adverse events from using CaP cement were experienced.

INTERPRETATION

CaP cement is an alternative to bone grafts in upper extremity metaphyseal corrective osteotomies in children, and also when greater corrections are necessary or several surgeries indicated during the growth period.

Single-stage Distal Radius Dome Osteotomy with Ulnar Diaphyseal Shortening and Distal Ulnar Epiphysiodesis in A Case of Manus Valgus Deformity Secondary to Post-Traumatic Physeal Growth Arrest - A Case Report

Introduction

Distal radius physeal growth arrest in children secondary to trauma is a rare complication. Various modalities of surgical treatment exist. Correction of severe deformity by a single-stage surgery is rare in current literature. We describe a case of surgically treated posttraumatic manus valgus deformity in an adolescent female with a satisfactory surgical outcome.

Case Report

A 13-year-old right-hand dominant girl presented to us with a painless, gradually progressive left wrist deformity for the past 3 years. She sustained a left wrist injury 3.5 years back for which she received native treatment. She was able to do most of her daily activities and cosmetic disability was her primary concern. She had a 20° fixed radial deviation deformity with further radial deviation up to 60°. Forearm rotation was from 70° supination to 60° pronation. Her pre-operative Mayo Modified Wrist Score was 25/10/10/25/70 (Pain/Satisfaction/Range of motion/Grip strength/Total). Radiologically, there was the obliteration of lateral distal radial physis with overgrowth of medial physis. Distal ulnar physeal overgrowth led to positive ulnar variance. Radiologically, the magnitude of deformity was 43° manus valgus (+24° radial inclination). We performed dome osteotomy at distal radius metaphysis with distal radius plating through modified Henry approach. Simultaneous ulnar diaphyseal shortening osteotomy with plate fixation was done through a dorsal approach and distal ulnar epiphysiodesis was done by physeal drilling to prevent future overgrowth. At 13 months follow-up, the wrist has clinically no deformity and radiologically 5° manus valgus (+24° radial inclination). Both the osteotomy sites have united and ulnar variance is restored. Now, her ulnar deviation was 20° and radial deviation was 30°. Her forearm rotational arc was maintained. Mayo Modified Wrist Score was 25/25/10/25/85 (Pain/Satisfaction/Range of motion/Grip strength/Total) with no hindrance of daily activity.

Conclusion

Correction of wrist deformity, restoration of ulnar variance, and normal wrist mechanics is possible in a single-stage surgery with judicious planning and can provide satisfactory result.

Morphology and kinematics studies of the upper extremity and its clinical application in deformity correction

Morphological and kinetic studies using computer-generated bone models are helpful for determining normal articular movements and various pathological conditions of the wrist joints, forearms, and elbow joints. Previous studies consisted of kinetic analyses that were carried out by superimposing three-dimensional bone models created on a computer on the basis of CT data obtained by scanning the limbs in several different positions. We applied the techniques used in such studies and have discovered a method for carrying out surgical procedure simulations aimed at correcting upper limb deformities. In addition, we have developed a system aimed at assisting surgical procedures conducted in accordance with simulations by using patient-matched guides (patient-matched instruments, PMI) and custom-made osteosynthesis plates. Our system has allowed for accurate anatomical corrections to be carried out three-dimensionally during a simple surgical procedure. The system was clinically used in the treatment of cubitus varus as well as malunited distal radial fractures and forearm fractures. As a result, accurate correction and favorable clinical outcomes have been achieved. Together with the development of therapeutic techniques, we have also simultaneously developed the related technological system, which consists of imaging protocols aimed at reducing the amount of radiation exposure and creating statistical shape models, as well as web-based tools for communication between physicians and engineers.

Is the contralateral tibia a reliable template for reconstruction: a three-dimensional anatomy cadaveric study

PURPOSE

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.

METHODS

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).

RESULTS

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.

CONCLUSION

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.

LEVEL OF EVIDENCE

Basic science.

A Graphic Overlay Method for Selection of Osteotomy Site in Chronic Radial Head Dislocation: An Evaluation of 3D-printed Bone Models

PURPOSE

Three-dimensional (3D) computed tomography imaging is now being used to generate 3D models for planning orthopaedic surgery, but the process remains time consuming and expensive. For chronic radial head dislocation, we have designed a graphic overlay approach that employs selected 3D computer images and widely available software to simplify the process of osteotomy site selection.

METHODS

We studied 5 patients (2 traumatic and 3 congenital) with unilateral radial head dislocation. These patients were treated with surgery based on traditional radiographs, but they also had full sets of 3D CT imaging done both before and after their surgery: these 3D CT images form the basis for this study. From the 3D CT images, each patient generated 3 sets of 3D-printed bone models: 2 copies of the preoperative condition, and 1 copy of the postoperative condition. One set of the preoperative models was then actually osteotomized and fixed in the manner suggested by our graphic technique. Arcs of rotation of the 3 sets of 3D-printed bone models were then compared.

RESULTS

Arcs of rotation of the 3 groups of bone models were significantly different, with the models osteotomized accordingly to our graphic technique having the widest arcs.

CONCLUSIONS

For chronic radial head dislocation, our graphic overlay approach simplifies the selection of the osteotomy site(s). Three-dimensional-printed bone models suggest that this approach could improve range of motion of the forearm in actual surgical practice.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

Rapid prototyping for patient-specific surgical orthopaedics guides: A systematic literature review

There has been a lot of hype surrounding the advantages to be gained from rapid prototyping processes in a number of fields, including medicine. Our literature review aims objectively to assess how effective patient-specific surgical guides manufactured using rapid prototyping are in a number of orthopaedic surgical applications. To this end, we carried out a systematic review to identify and analyse clinical and experimental literature studies in which rapid prototyping patient-specific surgical guides are used, focusing especially on those that entail quantifiable outcomes and, at the same time, providing details on the guides’ design and type of manufacturing process. Here, it should be mentioned that in this field there are not yet medium- or long-term data, and no information on revisions. In the reviewed studies, the reported positive opinions on the use of rapid prototyping patient-specific surgical guides relate to the following main advantages: reduction in operating times, low costs and improvements in the accuracy of surgical interventions thanks to guides’ personalisation. However, disadvantages and sources of errors which can cause patient-specific surgical guide failures are as well discussed by authors. Stereolithography is the main rapid prototyping process employed in these applications although fused deposition modelling or selective laser sintering processes can also satisfy the requirements of these applications in terms of material properties, manufacturing accuracy and construction time. Another of our findings was that individualised drill guides for spinal surgery are currently the favourite candidates for manufacture using rapid prototyping. Other emerging applications relate to complex orthopaedic surgery of the extremities: the forearm and foot. Several procedures such as osteotomies for radius malunions or tarsal coalition could become standard, thanks to the significant assistance provided by rapid prototyping patient-specific surgical guides in planning and performing such operations.

Three-Dimensional Corrective Osteotomy for Cubitus Varus Deformity with Use of Custom-Made Surgical Guides

Introduction

We present a detailed description of our preoperative planning and surgical technique for three-dimensional (3-D) corrective osteotomy with use of custom-made surgical guides for cubitus varus deformity after supracondylar fracture.

Step 1 Create Computer Bone Models from CT Data

Obtain CT data of both upper extremities and create computer bone models from these data.

Step 2 Evaluate the 3-D Deformity

Evaluate the deformity in three dimensions by comparing the affected humerus with the mirror image of the contralateral, normal humerus.

Step 3 Plan the 3-D Corrective Osteotomy

Simulate a 3-D corrective osteotomy on the basis of information obtained from the deformity evaluation.

Step 4 Operative Setup

Order the custom-made surgical guides that will assist you in reproducing the preoperative simulation during the actual surgery.

Step 5 Perform the 3-D Osteotomy Using the Custom-Made Surgical Guides

Perform the osteotomy using the custom-made surgical guides and achieve anatomical correction using the reduction guides.

Step 6 Postoperative Care

Apply a removable splint and have the patient start active and passive range-of-motion exercise after the splinting period has been completed.

Results

In our series of thirty patients, the mean humerus-elbow-wrist angle and tilting angle of the affected side were 18° (varus) and 25°, respectively, before surgery, which significantly improved to 6° (valgus) and 38°, respectively, after surgery.IndicationsContraindicationsPitfalls & Challenges.

Preoperative, computer simulation-based, three-dimensional corrective osteotomy for cubitus varus deformity with use of a custom-designed surgical device

BACKGROUND

Cubitus varus deformity after a supracondylar fracture classically includes varus, extension, and internal rotation components. However, to our knowledge, no reliable surgical method for three-dimensional corrective osteotomy has been established. We developed an intraoperative guide system involving a custom-made surgical template designed on the basis of a three-dimensional computer simulation incorporating computed tomography (CT) data. We aimed to investigate the feasibility of this novel technique for correcting cubitus varus deformity.

METHODS

Thirty consecutive patients (twenty-three males and seven females) with a cubitus varus deformity resulting from the malunion of a distal humeral supracondylar fracture were included in this study. Between October 2003 and May 2011, the patients underwent a three-dimensional corrective osteotomy with use of a custom-made surgical template. The patients were then followed for a minimum of twelve months. We evaluated radiographic parameters, including the humerus-elbow-wrist angle and tilting angle, as well as the ranges of motion of the elbow and shoulder at the time of the most recent follow-up. An overall clinical evaluation was performed.

RESULTS

Bone union was achieved at a mean of four months after surgery. The mean humerus-elbow-wrist angle and tilting angle on the affected side improved significantly from 18.2° (varus) and 25.0°, respectively, before surgery, to 5.8° (valgus) and 38.0°, respectively, after surgery. Hyperextension of the elbow and internal rotation of the shoulder were normalized in all patients. Early plate breakage was observed in one patient. One patient had mild recurrence of varus deformity. Twenty-seven patients had an excellent result, three had a good result, and none had a poor result.

CONCLUSIONS

Three-dimensional corrective osteotomy with the use of a custom-made surgical template that is designed and produced on the basis of computer simulation is a feasible and useful treatment option for cubitus varus deformity.

3-Dimensional prebent plate fixation in corrective osteotomy of malunited upper extremity fractures using a real-sized plastic bone model prepared by preoperative computer simulation

PURPOSE

To assess the clinical outcome and accuracy of prebent plate fixation in corrective osteotomy for malunited upper extremity fractures using a plastic bone model manufactured by preoperative computer simulation.

METHODS

Nine consecutive patients underwent computed tomography (CT)-based 3-dimensional corrective osteotomy for malunited upper extremity fractures. There were 4 cubitus varus deformities, 1 cubitus valgus deformity, and 4 forearm diaphyseal malunions. We constructed a computer model of the affected bones using the CT data and simulated the 3-dimensional deformity correction on a computer. A real-sized plastic model of the corrected bone was manufactured by rapid prototyping. We used a metal plate, prebent to fit the plastic bone model, in the actual surgery. Patients were evaluated after an average follow-up of 22 months (range, 14-36 mo). We retrospectively collected radiographic and clinical data at the most recent follow-up and compared them with preoperative data. We also performed CT after surgery and evaluated the error in corrective osteotomy as the difference between preoperative simulation and postoperative bone model.

RESULTS

The range of forearm rotation and grip strength in patients with forearm malunions improved after corrective osteotomies of the radius and ulna. Wrist pain, which 2 patients with forearm malunion had experienced before surgery, disappeared or decreased substantially after surgery. Radiographic examination indicated that preoperative angular deformities were nearly nonexistent after all corrective osteotomies. Three-dimensional errors in the corrective osteotomy using a prebent plate, as evaluated by CT data, were less than 3 mm and 2°.

CONCLUSIONS

Prebent plate fixation in corrective osteotomy for malunited upper extremity fractures using a 3-dimensionally corrected, real-sized plastic bone model prepared by preoperative computer simulation is a precise and relatively easily performed technique that results in satisfactory clinical outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Rapid prototyping in orthopaedic surgery: a user's guide

Rapid prototyping (RP) is applicable to orthopaedic problems involving three dimensions, particularly fractures, deformities, and reconstruction. In the past, RP has been hampered by cost and difficulties accessing the appropriate expertise. Here we outline the history of rapid prototyping and furthermore a process using open-source software to produce a high fidelity physical model from CT data. This greatly mitigates the expense associated with the technique, allowing surgeons to produce precise models for preoperative planning and procedure rehearsal. We describe the method with an illustrative case.

Open reduction and 3-dimensional ulnar osteotomy for chronic radial head dislocation using a computer-generated template: case report

We report a case of a radial head dislocation that was successfully treated 8 years after the initial injury, by open reduction of the radial head and 3-dimensional ulnar osteotomy, using a computer-generated template based on preoperative 3-dimensional computer simulation.

Distal radius osteotomy with volar locking plates based on computer simulation

BACKGROUND

Corrective osteotomy using dorsal plates and structural bone graft usually has been used for treating symptomatic distal radius malunions. However, the procedure is technically demanding and requires an extensive dorsal approach. Residual deformity is a relatively frequent complication of this technique.

QUESTIONS/PURPOSES

We evaluated the clinical applicability of a three-dimensional osteotomy using computer-aided design and manufacturing techniques with volar locking plates for distal radius malunions.

PATIENTS AND METHODS

Ten patients with metaphyseal radius malunions were treated. Corrective osteotomy was simulated with the help of three-dimensional bone surface models created using CT data. We simulated the most appropriate screw holes in the deformed radius using computer-aided design data of a locking plate. During surgery, using a custom-made surgical template, we predrilled the screw holes as simulated. After osteotomy, plate fixation using predrilled screw holes enabled automatic reduction of the distal radial fragment. Autogenous iliac cancellous bone was grafted after plate fixation.

RESULTS

The median volar tilt, radial inclination, and ulnar variance improved from -20°, 13°, and 6 mm, respectively, before surgery to 12°, 24°, and 1 mm, respectively, after surgery. The median wrist flexion improved from 33° before surgery to 60° after surgery. The median wrist extension was 70° before surgery and 65° after surgery. All patients experienced wrist pain before surgery, which disappeared or decreased after surgery.

CONCLUSIONS

Surgeons can operate precisely and easily using this advanced technique. It is a new treatment option for malunion of distal radius fractures.

Preoperative computer-assisted design templating of complex articular olecranon osteotomy: case report

Preoperative 3-dimensional modeling methods are commonly used in orthopedic surgery but there have been limited reports of their use for planning upper extremity surgery. In this report, we describe a case of a malunited olecranon fracture and its management using custom preoperative computed tomographic templating and mechanical modeling. One year after surgery, the patient demonstrated nearly full painless restoration of function and motion.