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Roytman GR, Salameh M, Rizzo SE, Dhodapkar MM, Tommasini SM, Wiznia DH, Yoo BJ. Sustentaculum fracture fixation with lateral plate or medial screw fixation are equivalent. Injury 2024; 55:111532. [PMID: 38614015 DOI: 10.1016/j.injury.2024.111532] [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: 12/07/2023] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Fixation of sustentaculum tali fractures is important to maintain the biomechanical function of the subtalar joint. A common method of fixation is securing the sustentacular fragment by way of a laterally based locking plate (LP). A medial approach with a single screw (MS) has been proposed as an alternative method of fixation. METHODS Five pairs of formalin-preserved cadaveric ankles with the subtalar joint and interosseous ligaments intact ("osseous cadavers") and four pairs of fresh-frozen cadaveric ankles with soft-tissue preserved dissected from mid-tibia down ("soft tissue cadavers") were used in the study. The left ankle was randomly assigned to one of the two fixation methods (LP or MS), while the right ankle was the opposite. These same steps for fixation were repeated for six synthetic ankle models. All models were loaded with a body mass of 80 kg. Statistical differences between LP and MS stiffness were determined using a paired t-test in cadavers and un-paired t-tests in synthetic ankles. RESULTS For osseous cadaveric ankles, LP demonstrated a mean stiffness of 232.95(SD: 59.96) N/mm, while MS was 239.72(SD:131.09) N/mm (p = 0.9293). For soft tissue cadaveric ankles, LP mean stiffness was 133.58(SD:37.84) N/mm, while MS was 134.88(SD:20.75) N/mm (p = 0.9578). For synthetic ankles, LP mean stiffness was 220.40(SD:81.93) N/mm, while MS was 261.50(SD:100.21) N/mm (p = 0.6116). CONCLUSIONS Across all three models, there was no significant difference between LP and MS methods. Retrospective observational studies are recommended to assess patient outcomes from each of the methods.
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Affiliation(s)
- Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, New Haven, CT, USA.
| | - Motasem Salameh
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Sarah E Rizzo
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Meera M Dhodapkar
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Steven M Tommasini
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, New Haven, CT, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA; Mechanical Engineering & Materials Science, Yale University School of Engineering & Applied Science, New Haven, CT, USA
| | - Brad J Yoo
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
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Bell C, Feizi A, Roytman GR, Ramji AF, Tommasini SM, Wiznia DH. Fabricating patient-specific 3D printed drill guides to treat femoral head avascular necrosis. 3D Print Med 2024; 10:10. [PMID: 38564090 PMCID: PMC10986134 DOI: 10.1186/s41205-024-00208-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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Femoral head avascular necrosis (AVN), or death of femoral head tissue due to a lack of blood supply, is a leading cause of total hip replacement for non-geriatric patients. Core decompression (CD) is an effective treatment to re-establish blood flow for patients with AVN. Techniques aimed at improving its efficacy are an area of active research. We propose the use of 3D printed drill guides to accurately guide therapeutic devices for CD. METHODS Using femur sawbones, image processing software, and 3D modeling software, we created a custom-built device with pre-determined drill trajectories and tested the feasibility of the 3D printed drill guides for CD. A fellowship trained orthopedic surgeon used the drill guide to position an 8 ga, 230 mm long decompression device in the three synthetic femurs. CT scans were taken of the sawbones with the drill guide and decompression device. CT scans were processed in the 3D modeling software. Descriptive statistics measuring the angular and needle-tip deviation were compared to the original virtually planned model. RESULTS Compared to the original 3D model, the trials had a mean displacement of 1.440 ± 1.03 mm and a mean angle deviation of 1.093 ± 0.749º. CONCLUSIONS The drill guides were demonstrated to accurately guide the decompression device along its predetermined drill trajectory. Accuracy was assessed by comparing values to literature-reported values and considered AVN lesion size. This study demonstrates the potential use of 3D printing technology to improve the efficacy of CD techniques.
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Affiliation(s)
- Cameron Bell
- Department of Orthopaedics and Rehabilitation, Yale University, Room 526B Farnham Memorial Building 330 Cedar St, New Haven, CT, 06510, USA.
- Department of Biomedical Engineering, Yale University, New Haven, CT, 06510, USA.
| | - Alborz Feizi
- Department of Orthopaedics and Rehabilitation, Yale University, Room 526B Farnham Memorial Building 330 Cedar St, New Haven, CT, 06510, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, 06510, USA
| | - Gregory R Roytman
- Department of Orthopaedics and Rehabilitation, Yale University, Room 526B Farnham Memorial Building 330 Cedar St, New Haven, CT, 06510, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, 06510, USA
| | - Alim F Ramji
- Department of Orthopaedics and Rehabilitation, Yale University, Room 526B Farnham Memorial Building 330 Cedar St, New Haven, CT, 06510, USA
| | - Steven M Tommasini
- Department of Orthopaedics and Rehabilitation, Yale University, Room 526B Farnham Memorial Building 330 Cedar St, New Haven, CT, 06510, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, 06510, USA
| | - Daniel H Wiznia
- Department of Orthopaedics and Rehabilitation, Yale University, Room 526B Farnham Memorial Building 330 Cedar St, New Haven, CT, 06510, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, 06510, USA
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Tung WS, Kunsel K, Roytman GR, Donnelley CA, Pratola D, Tommasini SM, Bernstein J, Wiznia DH. Off-the-Shelf Tibial Cone Sizes May Not Accommodate All Patients' Bone Morphology and May Lead to Cortical Breaches in Revision Total Knee Arthroplasty: A 3D Modeling Study. Arthroplast Today 2024; 26:101340. [PMID: 38455865 PMCID: PMC10918480 DOI: 10.1016/j.artd.2024.101340] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/23/2023] [Accepted: 02/03/2024] [Indexed: 03/09/2024] Open
Abstract
Background In revision total knee arthroplasty, tibial cones have demonstrated improved longevity and reduced incidence of aseptic loosening. Several currently available "off-the-shelf" (OTS) cone systems may not have sizes to accommodate all patient bone morphologies. Methods Computed tomographies from one hundred primary total knee arthroplasty patients and dimensions of 4 OTS cones were obtained. Press-fit stems were positioned in 3D tibia models to fit the diaphyseal trajectory. Cones were positioned around the stem at 1, 6, and 13 mm resections measured from the trough of the medial tibial plateau, simulating proximal tibial cuts and bone loss. Tibias were examined for cortical breaching following modeled cone preparation. Results Increased rate of breaching was observed as size and depth of the cone increased. In 2/49 (4.1%) male and 19/46 (41.3%) female tibias, cones could not be positioned without breaching. No breaches were found in 22/49 (45.0%) male and 5/46 (10.9%) female tibias. For every 1 centimeter increase in patient height, odds of breaching decreased by 12% (odds ratio: 0.88, confidence interval: 0.84, 0.92). For every size increase in cone width, odds of breaching increased by 34% (odds ratio: 1.34, confidence interval: 1.28, 1.47). Placing cones deeper also increased breaching compared to the 1 mm cut. Conclusions In revision total knee arthroplasty, smaller OTS or custom tibial cones may be needed to fit a patient's proximal tibial geometry. This is especially true in patients not accommodated by the OTS cone sizes we tested, which impacted shorter patients and/or those with substantial bone loss requiring more tibial resection and deeper cone placement. Use of smaller or custom tibial cones should be considered where indicated.
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Affiliation(s)
- Wei Shao Tung
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT, USA
| | - Kunsel Kunsel
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Gregory R. Roytman
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Claire A. Donnelley
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT, USA
| | | | - Steven M. Tommasini
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | | | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT, USA
- Department of Mechanical Engineering & Materials Science, Yale University, New Haven, CT, USA
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Bergemann R, Roytman GR, Ani L, Ramji AF, Leslie MP, Tommasini SM, Wiznia DH. The feasibility of a novel 3D-Printed patient specific cutting guide for extended trochanteric osteotomies. 3D Print Med 2024; 10:7. [PMID: 38427157 PMCID: PMC10905807 DOI: 10.1186/s41205-024-00204-3] [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: 08/18/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The extended trochanteric osteotomy (ETO) is a surgical technique utilized to expose the intramedullary canal of the proximal femur, protect the soft tissues and promote reliable healing. However, imprecise execution of the osteotomy can lead to fracture, soft tissue injury, non-union, and unnecessary morbidity. We developed a technique to create patient specific, 3D-printed cutting guides to aid in accurate positioning of the ETO and improve osteotomy quality and outcomes. METHODS Patient specific cutting guides were created based on CT scans using Synopysis Simpleware ScanIP and Solidworks. Custom 3D printed cutting guides were tested on synthetic femurs with foam cortical shells and on cadaveric femurs. To confirm accuracy of the osteotomies, dimensions of the performed osteotomies were compared to the virtually planned osteotomies. RESULTS Use of the patient specific ETO cutting guides resulted in successful osteotomies, exposing the femoral canal and the femoral stem both in synthetic sawbone and cadaveric testing. In cadaveric testing, the guides allowed for osteotomies without fracture and cuts made using the guide were accurate within 6 percent error from the virtually planned osteotomy. CONCLUSION The 3D-printed patient specific cutting guides used to aid in ETOs proved to be accurate. Through the iterative development of cutting guides, we found that a simple design was key to a reliable and accurate guide. While future clinical trials in human subjects are needed, we believe our custom 3D printed cutting guide design to be effective at aiding in performing ETOs for revision total hip arthroplasty surgeries.
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Affiliation(s)
- Reza Bergemann
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 333 Cedar St. FMB 5, New Haven, CT, 06511, USA.
| | - Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 333 Cedar St. FMB 5, New Haven, CT, 06511, USA
- Biomedical Engineering, Yale School of Engineering and Applied Sciences, Yale University, New Haven, USA
| | - Lidia Ani
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 333 Cedar St. FMB 5, New Haven, CT, 06511, USA
| | - Alim F Ramji
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 333 Cedar St. FMB 5, New Haven, CT, 06511, USA
| | - Michael P Leslie
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 333 Cedar St. FMB 5, New Haven, CT, 06511, USA
| | - Steven M Tommasini
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 333 Cedar St. FMB 5, New Haven, CT, 06511, USA
- Biomedical Engineering, Yale School of Engineering and Applied Sciences, Yale University, New Haven, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 333 Cedar St. FMB 5, New Haven, CT, 06511, USA
- Mechanical Engineering and Material Sciences, Yale School of Engineering and Applied Science, Yale University, New Haven, CT, USA
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Roytman GR, Jabbouri SS, O'Marr J, Raghuram A, Beitler B, Irshad S, Fram BR, Yoo BJ, Leslie MP, Riedel MD, Tommasini SM, Wiznia DH. Outcomes of Distal Third Femur Fractures in Patients 18 Years and Older: A Pilot Study. Cureus 2024; 16:e55136. [PMID: 38558586 PMCID: PMC10979706 DOI: 10.7759/cureus.55136] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The selection of the most optimal fixation method for fractures of the distal femur, whether intramedullary nail (NL), lateral locking plate (PL), or nail/plate (NP) is not always clear. This study retrospectively evaluates surgical patients with distal femur fractures and introduces a pilot study using cluster analysis to identify the most optimal fracture fixation method for a given fracture type. METHODS This is a retrospective cohort study of patients 18 years and older with an isolated distal femur fracture who presented to our Level-1 trauma center between January 1, 2012, and December 31, 2022, and obtained NL, PL, or NP implants. Patients with polytrauma and those without at least six months of follow-up were excluded. A chart review was used to obtain demographics, fracture classification, fixation method, and postoperative complications. A cluster analysis was performed. The following factors were used to determine a successful outcome: ambulatory status pre-injury and 6-12 months postoperatively, infection, non-union, mortality, and implant failure. RESULTS A total of 169 patients met inclusion criteria. No statistically significant association between the fracture classification and fixation type with overall outcome was found. However, patients treated with an NP (n = 14) had a success rate of 92.9% vs only a 68.1% success rate in those treated with a PL (n = 116) (p = 0.106). The most notable findings in the cluster analysis (15 total clusters) included transverse extraarticular fractures demonstrating 100% success if treated with NP (n = 6), 50% success with NL (n=2), and 78.57% success with PL fixation (n=14). NP constructs in complete articular fractures demonstrated success in 100% of patients (n = 5), whereas 77.78% of patients treated with NL (n = 9) and 61.36% of those treated with PL (n = 44). CONCLUSIONS Plate fixation was the predominant fixation method used for distal third femur fractures regardless of fracture classification. However, NP constructs trended towards improved success rates, especially in complete intraarticular and transverse extraarticular fractures, suggesting the potential benefit of additional fixation with these fractures. Cluster analysis provided a heuristic way of creating patient profiles in patients with distal third femur fractures. However, a larger cohort study is needed to corroborate these findings to ultimately develop a clinical decision-making tool that also accounts for patient specific characteristics.
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Affiliation(s)
- Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Sahir S Jabbouri
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Jamieson O'Marr
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Akshay Raghuram
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | | | - Suhail Irshad
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Brianna R Fram
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Brad J Yoo
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Michael P Leslie
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Matthew D Riedel
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Steven M Tommasini
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, USA
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Bell CE, Feizi A, Roytman GR, Ramji AF, Tommasini SM, Wiznia DH. Fabricating Patient-Specific 3D Printed Drill Guides to Treat Femoral Head Avascular Necrosis. Res Sq 2023:rs.3.rs-3650115. [PMID: 38106183 PMCID: PMC10723539 DOI: 10.21203/rs.3.rs-3650115/v1] [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] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background Femoral head avascular necrosis (AVN), or death of femoral head tissue due to a lack of blood supply, is a leading cause of total hip replacement for non-geriatric patients. Core decompression (CD) is an effective treatment to re-establish blood flow for patients with AVN. Techniques aimed at improving its efficacy are an area of active research. We propose the use of 3D printed drill guides to accurately guide therapeutic devices for CD. Methods Using femur sawbones, image processing software, and 3D modeling software, we created a custom-built device with pre-determined drill trajectories and tested the feasibility of the 3D printed drill guides for CD. A fellowship trained orthopedic surgeon used the drill guide to position an 8 ga, 230 mm long decompression device in the three synthetic femurs. CT scans were taken of the sawbones with the drill guide and decompression device. CT scans were processed in the 3D modeling software. Descriptive statistics measuring the angular and needle-tip deviation were compared to the original virtually planned model. Results Compared to the original 3D model, the trials had a mean displacement of 1.440±1.03 mm and a mean angle deviation of 1.093±0.749°. Conclusions The drill guides were demonstrated to accurately guide the decompression device along its predetermined drill trajectory. Accuracy was assessed by comparing values to literature-reported values and considered AVN lesion size. This study demonstrates the potential use of 3D printing technology to improve the efficacy of CD techniques.
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Roytman GR, Beitler B, LaMonica J, Spero M, Toy K, Ramji AF, Yoo B, Leslie MP, Baumgaertner M, Tommasini SM, Wiznia DH. An analytical model of lateral condylar plate working length. Clin Biomech (Bristol, Avon) 2023; 110:106129. [PMID: 37871506 PMCID: PMC10848195 DOI: 10.1016/j.clinbiomech.2023.106129] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The locking plate is a common device to treat distal femur fractures. Healing is affected by construct stiffness, thus many surgeon-controlled variables such as working length have been examined for their effects on strain at the fracture. No convenient analytical model which aids surgeons in determining working length has yet been described. We propose an analytical model and compare it to finite element analysis and cadaveric biomechanical testing. METHODS First, an analytical model based on a cantilever beam equation was derived. Next, a finite element model was developed based on a CT scan of a "fresh-frozen" cadaveric femur. Third, biomechanical testing in single-leg stance loading was performed on the cadaver. In all methods, strain at the fracture was recorded. An ANCOVA test was conducted to compare the strains. FINDINGS In all models, as the working length increased so did strain. For strain at the fracture, the shortest working length (35 mm) had a strain of 8% in the analytical model, 9% in the finite element model, and 7% for the cadaver. The longest working length (140 mm) demonstrated strain of 15% in the analytical model, and the finite element and biomechanical tests both demonstrated strain of 14%. INTERPRETATION The strain predicted by the analytical model was consistent with the strain observed in both the finite element and biomechanical models. As demonstrated in existing literature, increasing the working length increases strain at the fracture site. Additional work is required to refine and establish validity and reliability of the analytical model.
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Affiliation(s)
- Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520, USA.
| | - Brian Beitler
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Julia LaMonica
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Matthew Spero
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Kendal Toy
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Alim F Ramji
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Brad Yoo
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Michael P Leslie
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Michael Baumgaertner
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA
| | - Steven M Tommasini
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Place, New Haven, CT 06510, USA; Mechanical Engineering & Materials Science, Yale University School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520, USA
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Roytman GR, Cheung KH, Bathulapalli H, Goertz CM, Long CR, Lisi AJ. Characteristics of Chiropractic Patients in the Veterans Health Administration During the COVID-19 Pandemic: A Cross-Sectional Analysis. J Manipulative Physiol Ther 2022; 45:615-622. [PMID: 37294219 PMCID: PMC10254439 DOI: 10.1016/j.jmpt.2023.04.002] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/25/2023] [Accepted: 04/08/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether patient characteristics were associated with face-to-face (F2F) and telehealth visits for those receiving chiropractic care for musculoskeletal conditions in the US Veterans Health Administration (VHA) during the COVID-19 pandemic. METHODS A retrospective cross-sectional analysis of all patients (veterans, dependents, and spouses) who received chiropractic care nationwide at the VHA from March 1, 2020, to February 28, 2021, was performed. Patients were allocated into 1 of the following 3 groups: only telehealth visits, only F2F visits, and combined F2F and telehealth visits. Patient characteristics included age, sex, race, ethnicity, marital status, and Charlson Comorbidity Index. Multinomial logistic regression estimated associations of these variables with visit type. RESULTS The total number of unique patients seen by chiropractors between March 2020 and February 2021 was 62 658. Key findings were that patients of non-White race and Hispanic or Latino ethnicity were more likely to attend telehealth-only visits (Black [odds ratio 1.20, 95% confidence interval {1.10-1.31}], other races [1.36 {1.16-1.59}], and Hispanic or Latino [1.35 {1.20-1.52}]) and combination telehealth and F2F care (Black [1.32 {1.25-1.40}], other races [1.37 {1.23-1.52}], and Hispanic or Latino [1.63 {1.51-1.76}]). Patients younger than 40 years of age were more likely to choose telehealth visits ([1.13 {1.02-1.26}], 66-75 years [1.17 {1.01-1.35}], and >75 years [1.26 {1.06-1.51}] vs those 40-55 years of age). Sex, visit frequency, and Charlson Comorbidity Index showed significant relationships as well, while marital status did not. CONCLUSION During the COVID-19 pandemic, VHA patients with musculoskeletal complaints using chiropractic telehealth were more ethnically and racially diverse than those using F2F care alone.
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Affiliation(s)
- Gregory R Roytman
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut.
| | - Kei-Hoi Cheung
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harini Bathulapalli
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christine M Goertz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cynthia R Long
- Palmer Center for Chiropractic Research, Davenport, Iowa
| | - Anthony J Lisi
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
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Roytman GR, Cutler M, Milligan K, Tommasini SM, Wiznia DH. An open-access plug-in program for 3D modelling distinct material properties of cortical and trabecular bone. BMC Biomed Eng 2022; 4:8. [PMID: 36153577 PMCID: PMC9509591 DOI: 10.1186/s42490-022-00065-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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Finite element modelling the material behavior of bone in-silico is a powerful tool to predict the best suited surgical treatment for individual patients. RESULTS We demonstrate the development and use of a pre-processing plug-in program with a 3D modelling image processing software suite (Synopsys Simpleware, ScanIP) to assist with identifying, isolating, and defining cortical and trabecular bone material properties from patient specific computed tomography scans. The workflow starts by calibrating grayscale values of each constituent element with a phantom - a standardized object with defined densities. Using an established power law equation, we convert the apparent density value per voxel to a Young's Modulus. The resulting "calibrated" scan can be used for modeling and in-silico experimentation with Finite Element Analysis. CONCLUSIONS This process allows for the creation of realistic and personalized simulations to inform a surgeon's decision-making. We have made this plug-in program open and accessible as a supplemental file.
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Affiliation(s)
- Gregory R. Roytman
- grid.47100.320000000419368710Yale Center for Medical Informatics, Yale School of Medicine, 300 George St, New Haven, CT 06511 USA ,grid.281208.10000 0004 0419 3073VA Connecticut Healthcare System, Veterans Health Administration, 950 Campbell Ave, West Haven, CT 06516 USA ,grid.47100.320000000419368710Orthopedics and Rehabilitation, Yale School of Medicine, 47 College Place, New Haven, CT 06510 USA ,Biomedical Engineering, Yale School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520 USA
| | - Matan Cutler
- IsoPlexis Proteomic Solution, 35 NE Industrial Rd, Branford, CT 06405 USA
| | - Kenneth Milligan
- grid.47100.320000000419368710Orthopedics and Rehabilitation, Yale School of Medicine, 47 College Place, New Haven, CT 06510 USA
| | - Steven M. Tommasini
- grid.47100.320000000419368710Orthopedics and Rehabilitation, Yale School of Medicine, 47 College Place, New Haven, CT 06510 USA ,Biomedical Engineering, Yale School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520 USA
| | - Daniel H. Wiznia
- grid.47100.320000000419368710Orthopedics and Rehabilitation, Yale School of Medicine, 47 College Place, New Haven, CT 06510 USA ,Mechanical Engineering & Materials Science, Yale School of Engineering & Applied Science, 17 Hillhouse Avenue, New Haven, CT 06520 USA
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Beitler B, Roytman GR, Parmer G, Tommasini SM, Wiznia DH. Evaluating surface coatings to reduce bone cement adhesion to point of care 3D printed molds in the intraoperative setting. 3D Print Med 2022; 8:28. [PMID: 35960406 PMCID: PMC9373469 DOI: 10.1186/s41205-022-00156-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/15/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Polymethyl methacrylate, or "bone cement," can be used intraoperatively to replace damaged or diseased bone and to deliver local antibiotics. 3D printed molds allow surgeons to form personalized and custom shapes with bone cement. One factor hindering the clinical utility of anatomically accurate 3D printed molds is that cured bone cement can be difficult to remove due to the strong adhesion between the mold and the bone cement. One way to reduce the adhesion between the 3D printed mold and the cured bone cement is with the use of a surface coating, such as a lubricant. This study sought to determine the optimal surface coating to prevent bone cement adhesion to 3D printed molds that could be utilized within a sterile operating room environment. METHODS Hemispheric molds were 3D printed using a stereolithography printer. The molds were coated with four sterile surface coatings available in most operating theatres (light mineral oil, bacitracin ointment, lubricating jelly, and ultrasound transmission gel). Polymethyl methacrylate with tobramycin antibiotic was mixed and poured into the molds. The amount of force needed to "push out" the cured bone cement from the molds was measured to determine the efficacy of each surface coating. Tukey's multiple comparison test was performed to compare the results of the pushout test. RESULTS The average pushout force for the surface coatings, in increasing order, were as follows (mean ± standard deviation) --- bacitracin ointment: 9.10 ± 6.68 N, mineral oil: 104.93 ± 69.92 N, lubricating jelly: 147.76 ± 63.77 N, control group: 339.31 ± 305.20 N, ultrasound transmission gel 474.11 ± 94.77 N. Only the bacitracin ointment required significantly less pushout force than the control (p = 0.0123). CONCLUSIONS The bacitracin ointment was the most effective surface coating, allowing the bone cement to be pushed out of the mold using the least amount of force. In addition, the low standard deviation speaks to the reliability of the bacitracin ointment to reduce mold adhesion compared to the other surface coatings. Given its efficacy as well as its ubiquitous presence in the hospital operating room setting, bacitracin ointment is an excellent choice to prevent adhesion between bone cement and 3D printed molds intraoperatively.
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Affiliation(s)
- Brian Beitler
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 800 Howard Ave 1st Floor, New Haven, CT, 06519, USA.
| | - Gregory R Roytman
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 800 Howard Ave 1st Floor, New Haven, CT, 06519, USA
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, 300 George Street, Ste 501, New Haven, CT, 06511, USA
- VA Connecticut Healthcare System, Veterans Health Administration, 950 Campbell Ave, West Haven, CT, 06516, USA
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, Yale University, 17 Hillhouse Ave, New Haven, CT, 06511, USA
| | - Grace Parmer
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, Yale University, 17 Hillhouse Ave, New Haven, CT, 06511, USA
| | - Steven M Tommasini
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 800 Howard Ave 1st Floor, New Haven, CT, 06519, USA
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, Yale University, 17 Hillhouse Ave, New Haven, CT, 06511, USA
| | - Daniel H Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, 800 Howard Ave 1st Floor, New Haven, CT, 06519, USA
- Department of Mechanical Engineering & Materials Science, Yale School of Engineering and Applied Science, Yale University, 17 Hillhouse Ave, New Haven, CT, 06511, USA
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Roytman GR, Ramji AF, Beitler B, Yoo B, Leslie MP, Baumgaertner M, Tommasini S, Wiznia DH. Correction: Accuracy of guide wire placement for femoral neck stabilization using 3D printed drill guides. 3D Print Med 2022; 8:26. [PMID: 35943613 PMCID: PMC9361542 DOI: 10.1186/s41205-022-00153-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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Affiliation(s)
- Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA.
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.
- VA Connecticut Healthcare System, Veterans Health Administration, West Haven, CT, USA.
- Biomedical Engineering, Yale School of Engineering and Applied Science, Yale University, New Haven, CT, USA.
| | - Alim F Ramji
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Brian Beitler
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Brad Yoo
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Michael P Leslie
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Michael Baumgaertner
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Steven Tommasini
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
- Biomedical Engineering, Yale School of Engineering and Applied Science, Yale University, New Haven, CT, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
- Mechanical Engineering & Materials Science, Yale School of Engineering and Applied Science, Yale University, New Haven, CT, USA
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Roytman GR, Ramji AF, Beitler B, Yoo B, Leslie MP, Baumgaertner M, Tommasini S, Wiznia DH. Accuracy of guide wire placement for femoral neck stabilization using 3D printed drill guides. 3D Print Med 2022; 8:19. [PMID: 35781846 PMCID: PMC9254431 DOI: 10.1186/s41205-022-00146-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/07/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The goal of stabilization of the femoral neck is to limit morbidity and mortality from fracture. Of three potential methods of fixation, (three percutaneous screws, the Synthes Femoral Neck System, and a dynamic hip screw), each requires guide wire positioning of the implant(s) in the femoral neck and head. Consistent and accurate positioning of these systems is paramount to reduce surgical times, stabilize fractures effectively, and reduce complications. To help expedite surgery and achieve ideal implant positioning in the geriatric population, we have developed and validated a surgical planning methodology using 3D modelling and printing technology. METHODS Using image processing software, 3D surgical models were generated placing guide wires in a virtual model of an osteoporotic proximal femur sawbone. Three unique drill guides were created to achieve the optimal position for implant placement for each of the three different implant systems, and the guides were 3D printed. Subsequently, a trauma fellowship trained orthopedic surgeon used the 3D printed guides to position 2.8 mm diameter drill bit tipped guide wires into five osteoporotic sawbones for each of the three systems (fifteen sawbones total). Computed Tomography (CT) scans were then taken of each of the sawbones with the implants in place. 3D model renderings of the CT scans were created using image processing techniques and the displacement and angular deviations at guide wire entry to the optimal sawbone model were measured. RESULTS Across all three percutaneous screw guide wires, the average displacement was 3.19 ± 0.12 mm and the average angular deviation was 4.10 ± 0.17o. The Femoral Neck System guide wires had an average displacement of 1.59 ± 0.18 mm and average angular deviation of 2.81 ± 0.64o. The Dynamic Hip Screw had an average displacement of 1.03 ± 0.19 mm and average angular deviation of 2.59 ± 0.39o. CONCLUSION The use of custom 3D printed drill guides to assist with the positioning of guide wires proved to be accurate for each of the three types of surgical strategies. Guides which are used to place more than 1 guide wire may have lower positional accuracy, as the guide may shift during multiple wire insertions. We believe that personalized point of care drill guides provide an accurate intraoperative method for positioning implants into the femoral neck.
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Affiliation(s)
- Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA.
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.
- VA Connecticut Healthcare System, Veterans Health Administration, West Haven, CT, USA.
- Biomedical Engineering, Yale School of Engineering and Applied Science, Yale University, New Haven, CT, USA.
| | - Alim F Ramji
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Brian Beitler
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Brad Yoo
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Michael P Leslie
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Michael Baumgaertner
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Steven Tommasini
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
- Biomedical Engineering, Yale School of Engineering and Applied Science, Yale University, New Haven, CT, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, USA
- Mechanical Engineering & Materials Science, Yale School of Engineering and Applied Science, Yale University, New Haven, CT, USA
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Roytman GR, Ramji AF, Beitler B, Yoo B, Leslie MP, Baumgaertner M, Tommasini SM, Wiznia DH. Simulating Prophylactic Fixation Methods for Osteoporotic Femoral Neck Fracture Prevention. Geriatr Orthop Surg Rehabil 2022; 13:21514593221141376. [DOI: 10.1177/21514593221141376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Geriatric patients who suffer femoral neck fractures have high morbidity and mortality. Prophylactic fixation of the femoral neck is a potential avenue to reduce the incidence of femoral neck fractures. We studied 3 different implants traditionally used to stabilize the femoral neck: 6.5 mm cannulated screws (CANN), the femoral neck system (FNS) (Depuy Synthes), and the dynamic hip screw (DHS) (Depuy Synthes). Materials and Methods Five osteoporotic Sawbone femurs were used for each model and a control group. Two scenarios were investigated: single leg stance to measure construct stiffness and lateral impact to measure construct stiffness, energy to fracture, and qualitative examination of fracture patterns. Stiffness for each femur and energy to fracture for the lateral impact scenario were calculated and compared between groups using one-way ANOVA. Results DHS showed significantly higher stiffness than the other 2 implants and the control in single leg stance. In the lateral impact scenario, the DHS and CANN were significantly stiffer FNS and the control. Femurs implanted with CANN tended to fracture at the greater trochanter while FNS fractured in a transverse subtrochanteric pattern, and DHS fractured obliquely in the subtrochanteric region. Discussion FNS and DHS experienced fracture patterns less amenable to surgical correction. CANN and DHS proved better able to resist external forces in the lateral fall scenario. CANN also proved better able to resist external forces in the single leg stance scenario and experienced a more amenable fracture pattern in the lateral fall scenario. Conclusions FNS was less able to resist external forces compared with the other implants. This work informs the potential implications between the choice of implants that, although historically have not been used prophylactically, may be considered in the future for prophylactic stabilization of the femoral neck. Cadaveric study and clinical trials are recommended for further study.
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Affiliation(s)
- Gregory R. Roytman
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
- Biomedical Engineering, Yale University School of Engineering & Applied Science, New Haven, CT, USA
| | - Alim F. Ramji
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Brian Beitler
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Brad Yoo
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Michael P. Leslie
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Michael Baumgaertner
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Steven M. Tommasini
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
- Biomedical Engineering, Yale University School of Engineering & Applied Science, New Haven, CT, USA
| | - Daniel H. Wiznia
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
- Mechanical Engineering and Materials Science, Yale University School of Engineering and Applied Science, New Haven, CT, USA
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Roytman GR, Coleman BC, Corcoran KL, Goertz C, Long C, Lisi A. TEMPORARY REMOVAL: Changes in the Use of Telehealth and Face-To-Face Chiropractic Care in the Department of Veterans Affairs before and after the COVID-19 Pandemic. J Manipulative Physiol Ther 2021; 44:584-590. [PMID: 35249749 PMCID: PMC8742605 DOI: 10.1016/j.jmpt.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/07/2021] [Accepted: 12/12/2021] [Indexed: 11/01/2022]
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Roytman GR, Selby S, Cantu J, Cramer GD. A Novel and Accurate Palpation Method for Identification of the L4 Spinous Process: A Preliminary Study of Accuracy. J Manipulative Physiol Ther 2021; 44:398-407. [PMID: 34429213 DOI: 10.1016/j.jmpt.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 09/19/2020] [Accepted: 03/30/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to assess a novel method of lumbar spinous process (SP) palpation by using magnetic resonance imaging (MRI) high-signal marker reference standards for verification. METHODS Clinicians (doctors of chiropractic) in this study used either: (1) the standard/traditional method of identifying the L4 SP using the supracristal plane (n = 14) or (2) a novel method that manually induced sacral motion to identify the L5 and then the L4 SP (n = 54). The clinicians, blinded to the results of each other, used a grease pencil to mark the location identified as the L4 SP. An MRI high-signal marker then was taped across this location. The MRI scans were assessed by a radiologist, blinded to the palpation method, who extended a line posteriorly from the superior and inferior extent of the L4 SP and determined whether the high-signal marker was within the lines bordering the L4 SP (ie, "on-target"). RESULTS Palpation using the traditional method showed a 35.7% accuracy, with 5 of 14 "on target" and all "off target" being too superior. Palpation using the novel method showed 77.8% accuracy, with 42 of 54 "on target" and 3 "off target" being too superior and 9 "off target" too inferior. CONCLUSIONS The novel method performed better than the traditional method. The novel method shows promise. Additional prospective research should be conducted to fully assess the accuracy of the novel method compared with traditional methods of palpation.
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Affiliation(s)
- Gregory R Roytman
- Research Department, National University of Health Sciences, Lombard, Illinois
| | - Scott Selby
- Research Department, National University of Health Sciences, Lombard, Illinois; Private Practice, Wheaton, Illinois
| | - Joe Cantu
- Research Department, National University of Health Sciences, Lombard, Illinois; Private Practice, Charlottesville, Virginia
| | - Gregory D Cramer
- Research Department, National University of Health Sciences, Lombard, Illinois.
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