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Mui T, Shigematsu H, Ikejiri M, Kawasaki S, Tanaka Y. Reliability of the Risser+ grade for assessment of bone maturity in pediatric scoliosis cases: Investigation using standing and supine whole-spine radiograph. J Orthop Sci 2024:S0949-2658(24)00001-0. [PMID: 38216359 DOI: 10.1016/j.jos.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/16/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Although several radiography-based systems for assessing skeletal maturity are available to clinicians, the classical Risser grading system remains a clinical gold standard. For scoliosis follow-up, a standing whole-spine radiograph is usually used. However, in our clinical practice, we have occasionally encountered cases in which ossification of the iliac crest is seen differently in the standing and supine whole-spine radiography. Here, we aimed to clarify the reliability of the Risser+ grading system for supine versus standing position radiographs. METHODS This study recruited patients with all types of scoliosis who had been radiographed in both the standing and supine positions. We retrospectively evaluated the Risser+ grade of standing and supine whole-spine radiographs taken consecutively. Kappa statistics were computed to investigate the agreement between standing and supine Risser+ grades for this study. RESULTS We evaluated 111 patients (age: 12.6 ± 2.0; male-to-female = 23:88). The Kappa value for the standing and supine Risser+ grade systems was 0.74. The degree of agreement between the two positions for each Risser+ grade revealed high agreement for grades 0 and 5 in all cases, whereas grades 2 and 3 had low agreement. CONCLUSIONS Overall, there was substantial agreement between the Risser+ grades assigned to standing and supine position radiographs. However, disagreement was observed between standing and supine position radiographs assigned Risser+ grades of 2 or 3. Therefore, we have found a wide range in the visibility of iliac apophysis ossification of the iliac depending on the posture, and there are limitations in assessing bone maturity using the Risser+ grade alone. Clinicians should use other evaluation systems, in addition to the Risser+ system, to achieve a more accurate bone maturity assessment, especially for cases with standing position radiographs assigned Risser grades of 2 or 3.
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Affiliation(s)
- Takahiro Mui
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-shi, Nara, 634-8522, Japan
| | - Hideki Shigematsu
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-shi, Nara, 634-8522, Japan.
| | - Masaki Ikejiri
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-shi, Nara, 634-8522, Japan
| | - Sachiko Kawasaki
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-shi, Nara, 634-8522, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara-shi, Nara, 634-8522, Japan
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Del Prete CM, Tarantino D, Viva MG, Murgia M, Vergati D, Barassi G, Sparvieri E, Di Stanislao E, Perpetuini D, Russo EF, Filoni S, Pellegrino R. Spinal Orthosis in Adolescent Idiopathic Scoliosis: An Overview of the Braces Provided by the National Health Service in Italy. Medicina (Kaunas) 2023; 60:3. [PMID: 38276037 PMCID: PMC10818494 DOI: 10.3390/medicina60010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/27/2024]
Abstract
Adolescent idiopathic scoliosis (AIS) is a lateral, rotated curvature of the spine. It is a 3-dimensional deformity that arises in otherwise healthy children at or around puberty. AIS is the most common form of scoliosis in the pediatric population. The etiology is multifactorial, including genetic and environmental factors. The incidence is roughly equal between males and females, while there is a higher risk of progression in females. Guidelines for AIS treatment identify three levels of treatment: observation, physiotherapy scoliosis-specific exercises, and braces. In this paper, we carried out a review of the scientific literature about the indication and success rates of the braces provided for free by the National Health Service in Italy (SSN). Despite a general consensus on the efficacy of rigid bracing treatment and its use in AIS, an important heterogeneity about the treatment is present in the scientific literature, demonstrating a high degree of variability. The overall success rate of the braces provided by the SSN is high, suggesting an important therapeutic role in the treatment of AIS. Robust guidelines are needed to ensure uniform and effective treatments.
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Affiliation(s)
| | - Domiziano Tarantino
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy;
| | - Mattia Giuseppe Viva
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University of Rome, 00183 Rome, Italy; (M.G.V.); (M.M.)
| | - Massimiliano Murgia
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University of Rome, 00183 Rome, Italy; (M.G.V.); (M.M.)
| | | | - Giovanni Barassi
- Center for Physiotherapy, Rehabilitation and Re-Education-CeFiRR-Gemelli Molise, 86100 Campobasso, Italy;
| | | | | | - David Perpetuini
- Department of Engineering and Geology, University “G. d’Annunzio” of Chieti-Pescara, 65127 Pescara, Italy;
| | | | - Serena Filoni
- I.R.R.C.S. Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Raffaello Pellegrino
- Department of Scientific Research, Campus Ludes, Off-Campus Semmelweis University, 6912 Lugano–Pazzallo, Switzerland;
- Santa Chiara Institute, 73100 Lecce, Italy
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Xie LZ, Dou XY, Ge TH, Han XG, Zhang Q, Wang QL, Chen S, He D, Tian W. Deep learning-based identification of spine growth potential on EOS radiographs. Eur Radiol 2023:10.1007/s00330-023-10308-9. [PMID: 37848772 DOI: 10.1007/s00330-023-10308-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/21/2023] [Accepted: 08/15/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVES To develop an automatic computer-based method that can help clinicians in assessing spine growth potential based on EOS radiographs. METHODS We developed a deep learning-based (DL) algorithm that can mimic the human judgment process to automatically determine spine growth potential and the Risser sign based on full-length spine EOS radiographs. A total of 3383 EOS cases were collected and used for the training and test of the algorithm. Subsequently, the completed DL algorithm underwent clinical validation on an additional 440 cases and was compared to the evaluations of four clinicians. RESULTS Regarding the Risser sign, the weighted kappa value of our DL algorithm was 0.933, while that of the four clinicians ranged from 0.909 to 0.930. In the assessment of spine growth potential, the kappa value of our DL algorithm was 0.944, while the kappa values of the four clinicians were 0.916, 0.934, 0.911, and 0.920, respectively. Furthermore, our DL algorithm obtained a slightly higher accuracy (0.973) and Youden index (0.952) compared to the best values achieved by the four clinicians. In addition, the speed of our DL algorithm was 15.2 ± 0.3 s/40 cases, much faster than the inference speeds of the clinicians, ranging from 177.2 ± 28.0 s/40 cases to 241.2 ± 64.1 s/40 cases. CONCLUSIONS Our algorithm demonstrated comparable or even better performance compared to clinicians in assessing spine growth potential. This stable, efficient, and convenient algorithm seems to be a promising approach to assist doctors in clinical practice and deserves further study. CLINICAL RELEVANCE STATEMENT This method has the ability to quickly ascertain the spine growth potential based on EOS radiographs, and it holds promise to provide assistance to busy doctors in certain clinical scenarios. KEY POINTS • In the clinic, there is no available computer-based method that can automatically assess spine growth potential. • We developed a deep learning-based method that could automatically ascertain spine growth potential. • Compared with the results of the clinicians, our algorithm got comparable results.
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Affiliation(s)
- Lin-Zhen Xie
- Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin-Yu Dou
- Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Teng-Hui Ge
- Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Guang Han
- Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Zhang
- Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi-Long Wang
- Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuo Chen
- Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Da He
- Peking University Fourth School of Clinical Medicine, Beijing, China.
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China.
| | - Wei Tian
- Peking University Fourth School of Clinical Medicine, Beijing, China.
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China.
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Heegaard M, Tøndevold N, Dahl B, Andersen TB, Gehrchen M, Ohrt-Nissen S. Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing? Eur Spine J 2023; 32:3077-3083. [PMID: 37314578 DOI: 10.1007/s00586-023-07808-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/03/2023] [Accepted: 06/01/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing. METHODS AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs. RESULTS One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67). CONCLUSION Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.
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Affiliation(s)
- Martin Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Thomas B Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
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Marsiolo M, Careri S, Bandinelli D, Toniolo RM, Aulisa AG. Vertebral Rotation in Functional Scoliosis Caused by Limb-Length Inequality: Correlation between Rotation, Limb Length Inequality, and Obliquity of the Sacral Shelf. J Clin Med 2023; 12:5571. [PMID: 37685636 PMCID: PMC10488457 DOI: 10.3390/jcm12175571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Scoliosis is a structured rotatory deformity of the spine defined as >10° Cobb. Functional scoliosis (FS) is a curve < 10° Cobb, which is non-rotational and correctable. FS is often secondary to leg length inequality (LLI). To observe vertebral rotation (VR) in functional scoliosis due to LLI, one must demonstrate a correlation between LLI, sacral shelf inclination (SSI), and VR and discover a predictive value of LLI capable of inducing rotation. METHODS We studied 89 patients with dorso-lumbar or lumbar curves < 15° Cobb and radiographs of the spine and pelvis. We measured LLI, SSI, and VR. The patients were divided into VR and without rotation (WVR) groups. Statistical analysis was performed. RESULTS The mean LLI value was 6.5 ± 4.59 mm, and the mean SSI was 2.8 ± 2.53 mm. The mean value of LLI was 5.2 ± 4.87 mm in the WVR group and 7.4 ± 4.18 mm in the VR group. The mean SSI value for WVR was 1.4 ± 2.00 and that for VR was 3.9 ± 2.39. For each mm of LLI, it was possible to predict 0.12° of rotation. LLI ±5 mm increased the probability of rotation (R2.08 p < 0.0016), while this was ±2 mm for SSI (R2 0.22 p < 0.01). Each mm of LLI corresponded to 0.3 mm of SSI (R2 0.29, p < 0.01). CONCLUSIONS FS secondary to LLI can cause VR, and 5 mm of LLI can cause SSI and rotation.
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Affiliation(s)
- Martina Marsiolo
- U.O.C. of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, Istituto di Ricerca e Cura a Carattere Sceintifico (IRCCS), 00165 Rome, Italy; (S.C.); (D.B.); (R.M.T.); (A.G.A.)
| | - Silvia Careri
- U.O.C. of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, Istituto di Ricerca e Cura a Carattere Sceintifico (IRCCS), 00165 Rome, Italy; (S.C.); (D.B.); (R.M.T.); (A.G.A.)
| | - Diletta Bandinelli
- U.O.C. of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, Istituto di Ricerca e Cura a Carattere Sceintifico (IRCCS), 00165 Rome, Italy; (S.C.); (D.B.); (R.M.T.); (A.G.A.)
| | - Renato Maria Toniolo
- U.O.C. of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, Istituto di Ricerca e Cura a Carattere Sceintifico (IRCCS), 00165 Rome, Italy; (S.C.); (D.B.); (R.M.T.); (A.G.A.)
| | - Angelo Gabriele Aulisa
- U.O.C. of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, Istituto di Ricerca e Cura a Carattere Sceintifico (IRCCS), 00165 Rome, Italy; (S.C.); (D.B.); (R.M.T.); (A.G.A.)
- Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, 03043 Cassino, Italy
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Cheung PWH, Cheung JPY. Can the proximal humeral ossification system (PHOS) effectively guide brace weaning in patients with adolescent idiopathic scoliosis? Eur Spine J 2023; 32:2185-2195. [PMID: 37100964 DOI: 10.1007/s00586-023-07693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 03/10/2023] [Accepted: 03/28/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE The proximal humeral epiphyses can be conveniently viewed in routine spine radiographs. This study aimed to investigate whether the proximal humeral epiphyseal ossification system (PHOS) can be used to determine the timing of brace weaning in adolescent idiopathic scoliosis (AIS), as assessed by the rate of curve progression after brace weaning. METHODS A total of 107 patients with AIS who had weaned brace-wear at Risser Stage ≥ 4, no bodily growth and post-menarche ≥ 2 years between 7/2014 and 2/2016 were studied. Increase in major curve Cobb angle > 5° between weaning and 2-year follow-up was considered curve progression. Skeletal maturity was assessed using the PHOS, distal radius and ulna (DRU) classification, Risser and Sanders staging. Curve progression rate per maturity grading at weaning was examined. RESULTS After brace-wear weaning, 12.1% of the patients experienced curve progression. Curve progression rate for weaning at PHOS Stage 5 was 0% for curves < 40°, and 20.0% for curves ≥ 40°. No curve progression occurred when weaning at PHOS Stage 5 with radius grade of 10 for curves ≥ 40°. Factors associated with curve progression were: Months post-menarche (p = 0.021), weaning Cobb angle (p = 0.002), curves < 40° versus ≥ 40° (p = 0.009), radius (p = 0.006) and ulna (p = 0.025) grades, and Sanders stages (p = 0.025), but not PHOS stages (p = 0.454). CONCLUSION PHOS can be a useful maturity indicator for brace-wear weaning in AIS, with PHOS Stage 5 having no post-weaning curve progression in curves < 40°. For large curves ≥ 40°, PHOS Stage 5 is also effective in indicating the timing of weaning together with radius grade ≥ 10.
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Affiliation(s)
- Prudence Wing Hang Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Professorial Block, 5thFloor, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, China
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Professorial Block, 5thFloor, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, China.
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Pavone V, Caldaci A, Mangano GRA, Maria FD, Panvini FMC, Sapienza M, Vescio A, Roggio F, Musumeci G, Testa G. The Incidence of Bracing Treatment on Static and Dynamic Baropodometric Parameters in Adolescent Idiopathic Scoliosis. Children (Basel) 2022; 9. [PMID: 36360336 DOI: 10.3390/children9111608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
Postural balance is an important but not well-studied concept in the treatment of adolescent scoliosis. The aim of this study was to assess whether conservative treatment with Sforzesco bracing induced negative perturbations on postural stability, as related to static, postural, and dynamic baropodometric indicators. Twelve subjects (12 females, aged 11−16) with moderate AIS, were selected among a group of 97 patients. Inclusion criteria were: (1) confirmed diagnosis of moderate AIS (Cobb angle of 21° to 35° for the primary curve); (2) thoracic or thoracolumbar primary curve; (3) skeletal immaturity with growth cartilage visible on pretreatment radiographs (Risser < 5); (4) chronological age between 11 and 16 years; and (5) Sforzesco bracing treatment. All patients underwent a physical examination and radiological measurements with anteroposterior and lateral scans. Static, postural, and dynamic assessments were performed twice by barefoot patients, with and without Sforzesco bracing. Comparison between demographic, anthropometric, and clinical data highlighted a homogeneity of the sample. We evaluated the point of maximum pressure with and without bracing and found no statistically significant differences (p value = 0.22). In postural measurements, the laterolateral oscillations, anteroposterior oscillations, and average speed of oscillations were evaluated, comparing measurements with and without bracing. There were no statistically significant differences, except for the mean rate of oscillation, which was slightly increased in the recordings with a brace compared to those without a brace, p value = 0.045. Our findings show no statistically significant differences (p > 0.05) in static, postural, and dynamic baropodometric indicators.
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Alfraihat A, Samdani AF, Balasubramanian S. Predicting curve progression for adolescent idiopathic scoliosis using random forest model. PLoS One 2022; 17:e0273002. [PMID: 35951527 PMCID: PMC9371275 DOI: 10.1371/journal.pone.0273002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/30/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional (3D) spinal deformity characterized by coronal curvature and rotational deformity. Predicting curve progression is important for the selection and timing of treatment. Although there is a consensus in the literature regarding prognostic factors associated with curve progression, the order of importance, as well as the combination of factors that are most predictive of curve progression is unknown.
Objectives
(1) create an ordered list of prognostic factors that most contribute to curve progression, and (2) develop and validate a Machine Learning (ML) model to predict the final major Cobb angle in AIS patients.
Methods
193 AIS patients were selected for the current study. Preoperative PA, lateral and lateral bending radiographs were retrospectively obtained from the Shriners Hospitals for Children. Demographic and radiographic features, previously reported to be associated with curve progression, were collected. Sequential Backward Floating Selection (SBFS) was used to select a subset of the most predictive features. Based on the performance of several machine learning methods, a Random Forest (RF) regressor model was used to provide the importance rank of prognostic features and to predict the final major Cobb angle.
Results
The seven most predictive prognostic features in the order of importance were initial major Cobb angle, flexibility, initial lumbar lordosis angle, initial thoracic kyphosis angle, age at last visit, number of levels involved, and Risser "+" stage at the first visit. The RF model predicted the final major Cobb angle with a Mean Absolute Error (MAE) of 4.64 degrees.
Conclusion
A RF model was developed and validated to identify the most important prognostic features for curve progression and predict the final major Cobb angle. It is possible to predict the final major Cobb angle value within 5 degrees error from 2D radiographic features. Such methods could be directly applied to guide intervention timing and optimization for AIS treatment.
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Cheung PWH, Cheung JPY. Does the Use of Sanders Staging and Distal Radius and Ulna Classification Avoid Mismatches in Growth Assessment with Risser Staging Alone? Clin Orthop Relat Res 2021; 479:2516-2530. [PMID: 34036944 PMCID: PMC8509998 DOI: 10.1097/corr.0000000000001817] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 04/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although Risser stages are visible on the same radiograph of the spine, Risser staging is criticized for its insensitivity in estimating the remaining growth potential and its weak correlation with curve progression in patients with adolescent idiopathic scoliosis. Risser staging is frequently accompanied by other skeletal maturity indices to increase its precision for assessing pubertal growth. However, it remains unknown whether there is any discrepancy between various maturity parameters and the extent of this discrepancy when these indices are used concurrently to assess pubertal growth landmarks, which are important for the timing of brace initiation and weaning. QUESTIONS/PURPOSES (1) What is the chronologic order of skeletal maturity grades based on the growth rate and curve progression rate in patients with adolescent idiopathic scoliosis? (2) What are the discrepancies among the grades of each maturity index for indicating the peak growth and start of the growth plateau, and how do these indices correspond to each other? (3) What is the effectiveness of Risser staging, Sanders staging, and the distal radius and ulna classification in assessing peak growth and the beginning of the growth plateau? METHODS Between 2014 and 2017, a total of 13,536 patients diagnosed with adolescent idiopathic scoliosis were treated at our tertiary clinic. Of those, 3864 patients with a radiograph of the left hand and wrist and a posteroanterior radiograph of the spine at the same visits including initial presentation were considered potentially eligible for this study. Minimum follow-up was defined as 6 months from the first visit, and the follow-up duration was defined as 2 years since initial consultation. In all, 48% (1867 of 3864) of patients were eligible, of which 26% (485 of 1867) were excluded because they were prescribed bracing at the first consultation. These patients visited the subsequent clinics wearing the brace, which might have affected body height measurement. Six percent (117 of 1867) of eligible patients were also excluded as their major coronal Cobb angle reached the surgical threshold of 50° and had undergone surgery before skeletal maturity. Another 21% (387 of 1867) of patients were lost before minimum follow-up or had incomplete data, leaving 47% (878) for analysis. These 878 patients with 1139 skeletal maturity assessments were studied; 74% (648 of 878) were girls. Standing body height was measured in a standardized manner by a wall-mounted stadiometer. Several surgeons measured curve magnitude as per routine clinical consultation, skeletal maturity was measured according to the distal radius and ulna classification, and two raters measured Risser and Sanders stages. Reliability tests were performed with satisfaction. Data were collected for the included patients at multiple points when skeletal maturity was assessed, and only up to when brace wear started for those who eventually had bracing. The growth rate and curve progression rate were calculated by the change of body height and major coronal Cobb angle over the number of months elapsed between the initial visit and next follow-up. At each skeletal maturity grading, we examined the growth rate (in centimeters per month) and curve progression rate (in degrees per month) since the skeletal maturity assessment, as well as the mean age at which this maturity grading occurred. Each patient was then individually assessed for whether he or she was experiencing peak growth and the beginning of growth plateau at each timepoint by comparing the calculated growth rate with the previously defined peak growth rate of ≥ 0.7 cm per month and the beginning of growth plateau rate of ≤ 0.15 cm per month in this adolescent idiopathic scoliosis population. Among the timepoints at which the peak growth and the beginning of growth plateau occurred, the median maturity grade of each maturity index was identified as the benchmark grade for comparison between indices. We used the McNemar test to investigate whether pubertal growth landmarks were identified by specific maturity grades concurrently. We assessed the effectiveness of these skeletal maturity indices by the difference in proportions (%) between two benchmark grades in indicating peak growth and the growth plateau. RESULTS For girls, the chronological order of maturity grades that indicated peak growth was the radius grade, ulna grade, Sanders stage, and Risser stage. Curve progression peaked between the age of 11.6 and 12.1 years at a similar timing by all maturity indices for girls but was inconsistent for boys. For both sexes, radius (R) grade 6, ulna (U) grade 5, Sanders stage (SS) 3, and Risser stage 0+ were the median grades for peak growth, whereas Risser stage 4, R8/9, U7/8, and SS6/7 indicated the beginning of the growth plateau. The largest discrepancy between maturity indices was represented by Risser stage 0+, which corresponded to six grades of the Sanders staging system (SS2 to SS7) and to R6 in only 41% (62 of 152) of girls in the whole cohort. Despite Risser stage 0+ corresponding to the wide range of Sanders and distal radius and ulna grades, none of the R6, U5, SS3, and Risser stage 0+ was found more effective than another grade in indicating the peak growth in girls. R6 most effectively indicated the peak growth in boys, and Risser stage 0+ was the least effective. For the beginning of the growth plateau in girls, SS6/7 was the most effective indicator, followed by U7/8. Risser stage 4 was the least effective because it indicated 29% (95% CI 21% to 36%; p < 0.001) fewer patients who reached the beginning of the growth plateau than did those with R8/9. Risser stage 4 also indicated 36% (95% CI 28% to 43%; p < 0.001) fewer patients who reached the beginning of the growth plateau than those indicated by U7/8, and it identified 39% fewer patients than SS6/7 (95% CI 32% to 47%; p < 0.001). For boys, similarly, R8/9, U7/8, and SS6/7 were all more effective than Risser stage 4 in identifying when the growth plateau began. CONCLUSION Risser stage 0+ corresponds to a wide range of Sanders and distal radius and ulna grades. Risser stage 0+ is least effective in indicating the peak growth in boys, and Risser stage 4 is the least effective maturity grade for indicating when the growth plateau starts in both sexes. The concurrent use of R6 and SS3 can be useful for detecting the peak growth, and SS6/7 in conjunction with U7/8 is most effective in indicating the beginning of the growth plateau. Using a combination of specific grades of Sanders staging and the distal radius and ulna classification can indicate pubertal growth landmarks with reduced risk of underestimating or overestimating skeletal maturity. These findings may aid in refining clinical decision-making of brace initiation and weaning at a more precise timing. Among Risser stage 0, the appearance of R6, U5, and SS3 provide the most effective assessment of peak growth that can indicate the most effective bracing period within which curve progression occurs. For initiation of the growth plateau, Risser 4 is not useful, and SS6/7, R8/9 and U7/8 should be used instead. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
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10
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Trisolino G, Stallone S, Castagnini F, Bordini B, Cosentino M, Lucchini S, Zarantonello P, Ferrari D, Dallari D, Traina F. Cementless Ceramic-on-Ceramic Total Hip Replacement in Children and Adolescents. Children (Basel) 2021; 8:children8100858. [PMID: 34682123 PMCID: PMC8534320 DOI: 10.3390/children8100858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 02/07/2023]
Abstract
Background: total hip replacement (THR) is a rare surgical option in children and adolescents with disabling hip diseases. The aim of this study is to report results from a retrospective cohort of patients aged 18 years or less who underwent cementless Ceramic-on-Ceramic (CoC) THR at a single institution, investigating clinical and radiographic outcomes, survival rates, and reasons for revision of the implants. Materials and methods: we queried the Registry of Prosthetic Orthopedic Implants (RIPO) to identify all children and adolescents undergoing THR between 2000 and 2019 at a single Institution. Inclusion criteria were patients undergoing cementless CoC THR, aged less than 18 years at surgery, followed for at least 2 years. Sixty-eight patients (74 hips) matched all the inclusion criteria and were enrolled in the study. We assessed the clinical and radiographic outcomes, the rate of complications, the survival rate, and reasons for revision of the implants. Results: The mean follow-up was 6.6 ± 4.4 years (range 2-20). The most frequent reason for THR was post-traumatic or chemotherapy-induced avascular necrosis (38%). The overall survival rate of the cohort was 97.6% (95% CI: 84.9-99.7%) at 5 years of follow-up, 94.4% (95% CI: 79.8-98.6%) at 10 years and 15 years of follow-up. Two THR in two patients (2.7%) required revision. With the numbers available, Cox regression analysis could not detect any significant interaction between preoperative or intraoperative variables and implant survivorship (p-value 0.242 to 0.989)." The average HOOS was 85 ± 14.3 (range 30.6-100). Overall, 23 patients (48%) reported excellent HOOS scores (>90 points), 21 patients (44%) reported acceptable HOOS scores (60-90 points) while 4 patients (8%) reported poor outcomes (<60 points). Twenty-one patients (43%) were regularly involved into moderate- to high-intensity sport activities (UCLA ≥ 6). Conclusions: Cementless CoC THR is a successful procedure in children and teenagers, having demonstrated high implant survivorship and low rates of complications and failure. A meticulous preoperative planning and implant selection is mandatory, to avoid implant malposition, which is the main reason of failure and revision in these cases. Further studies are needed to assess the impact of the THR on the psychosocial wellbeing of teenagers, as well as risks and benefits and cost-effectiveness in comparison to the hip preserving surgical procedures.
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Affiliation(s)
- Giovanni Trisolino
- Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (P.Z.); (D.F.)
- Correspondence: (G.T.); (S.S.)
| | - Stefano Stallone
- Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (P.Z.); (D.F.)
- Correspondence: (G.T.); (S.S.)
| | - Francesco Castagnini
- Orthopaedic-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.C.); (S.L.); (F.T.)
| | - Barbara Bordini
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (B.B.); (M.C.)
| | - Monica Cosentino
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (B.B.); (M.C.)
| | - Stefano Lucchini
- Orthopaedic-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.C.); (S.L.); (F.T.)
| | - Paola Zarantonello
- Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (P.Z.); (D.F.)
| | - Daniele Ferrari
- Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (P.Z.); (D.F.)
| | - Dante Dallari
- Conservative Orthopedic Surgery and Innovative Techniques, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Francesco Traina
- Orthopaedic-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.C.); (S.L.); (F.T.)
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11
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Verhofste BP, Whitaker AT, Glotzbecker MP, Miller PE, Karlin LI, Hedequist DJ, Emans JB, Hresko MT. Efficacy of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis curves between 40° and 60°. Spine Deform 2020; 8:911-920. [PMID: 32394324 DOI: 10.1007/s43390-020-00131-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 04/25/2020] [Indexed: 01/31/2023]
Abstract
STUDY DESIGN Retrospective case-series. OBJECTIVES To evaluate the outcomes of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis (IS) curves ≥ 40°. BACKGROUND In contrast to prior beliefs, the recent studies have reported successful outcomes with brace treatment may occur in some patients with moderate-severe scoliosis ≥ 40°. Despite other encouraging case-series, non-operative treatment is rarely attempted and the efficacy of bracing large curves remains uncertain. METHODS 100 skeletally immature children (mean 11.8 ± 2.36 years; range 6.1-16.5) with IS ≥ 40° were identified. 80 were adolescent IS (80%) and 20 juvenile IS (20%). The Risser plus score was used to evaluate skeletal maturity. 66 children were Risser 0 (66%). SRS-SOSORT outcome guidelines were used: > 5° progression, stabilization between - 5° and 5° and, > 5° improvement. RESULTS Mean initial Cobb was 45° ± 3.9° (range 40°-59°), with in-brace and % correction of 30° ± 8.7° (range 7°-48°) and 34 ± 17.5% (range 2-84%), respectively. 57 progressed (57%), 32 stabilized (32%), and 11 improved (11%) after a median of 1.8 years (IQR 1.2-2.9). Open triradiate cartilage at presentation (p = 0.005) and less in-brace correction (p = 0.009) were associated with progression. 58 children (58%) underwent surgery after a mean of 3.0 years (range 0.7-7.3). Surgical patients were younger (11.2 vs. 12.7 years; p = 0.003), more often Risser 0 (79% vs. 48%; p < 0.001); however, presented with similar curves (45° vs. 44°; p = 0.31). Open triradiate cartilage at presentation (OR 15.3; 95% CI 4.3-54.6; p < 0.001) and less in-brace correction (p = 0.03) increased the likelihood of surgery. All 20 JIS patients avoided temporary growth rods, with 18 (90%) eventually requiring surgery. CONCLUSION Non-operative treatment was successful in 42% of children. Risk factors for surgery were younger age, open triradiates, and less in-brace correction. Bracing can be effective in delaying surgery until skeletal maturity in patients with curves ≥ 40°. Patients should be counseled on the risks and benefits of bracing and surgery. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Bram P Verhofste
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Amanda T Whitaker
- Department of Orthopaedic Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Patricia E Miller
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Lawrence I Karlin
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Daniel J Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Michael Timothy Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School Teaching Hospital, Hunnewell 2, 300 Longwood Ave HU 221, Boston, MA, 02115, USA.
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12
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Kaddioui H, Duong L, Joncas J, Bellefleur C, Nahle I, Chémaly O, Nault ML, Parent S, Grimard G, Labelle H. Convolutional Neural Networks for Automatic Risser Stage Assessment. Radiol Artif Intell 2020; 2:e180063. [PMID: 33937822 PMCID: PMC8082353 DOI: 10.1148/ryai.2020180063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/11/2022]
Abstract
PURPOSE To develop an automatic method for the assessment of the Risser stage using deep learning that could be used in the management panel of adolescent idiopathic scoliosis (AIS). MATERIALS AND METHODS In this institutional review board approved-study, a total of 1830 posteroanterior radiographs of patients with AIS (age range, 10-18 years, 70% female) were collected retrospectively and graded manually by six trained readers using the United States Risser staging system. Each radiograph was preprocessed and cropped to include the entire pelvic region. A convolutional neural network was trained to automatically grade conventional radiographs according to the Risser classification. The network was then validated by comparing its accuracy against the interobserver variability of six trained graders from the authors' institution using the Fleiss κ statistical measure. RESULTS Overall agreement between the six observers was fair, with a κ coefficient of 0.65 for the experienced graders and agreement of 74.5%. The automatic grading method obtained a κ coefficient of 0.72, which is a substantial agreement with the ground truth, and an overall accuracy of 78.0%. CONCLUSION The high accuracy of the model presented here compared with human readers suggests that this work may provide a new method for standardization of Risser grading. The model could assist physicians with the task, as well as provide additional insights in the assessment of bone maturity based on radiographs.© RSNA, 2020.
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Affiliation(s)
- Houda Kaddioui
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Luc Duong
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Julie Joncas
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Christian Bellefleur
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Imad Nahle
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Olivier Chémaly
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Marie-Lyne Nault
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Stefan Parent
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Guy Grimard
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
| | - Hubert Labelle
- From the Department of Software and IT Engineering, Ecole de Technologie Supérieure, 1100 rue Notre-Dame Ouest, Montréal, QC, Canada H3C 1K3 (H.K., L.D.); Division of Orthopedics, Sainte-Justine Hospital, Montréal, Canada (J.J., C.B., I.N., O.C., S.P., G.G., H.L.); and Department of Surgery, Université de Montréal, Montréal, Canada (M.L.N., S.P., G.G., H.L.)
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