Experimental assessment of pelvis slipping during postless traction for orthopaedic applications.

BACKGROUND: The application of lower limb traction during hip arthroscopy and femur fractures osteosynthesis is commonplace in orthopaedic surgeries. Traditional methods utilize a perineal post on a traction table, leading to soft tissue damage and nerve neuropraxia. A postless technique, using high-friction pads, has been considered as a potential damage-free alternative. However, whether these pads sufficiently prevent patient displacement remains unknown. Thus, this study systematically assesses the efficacy of commercial high-friction pads (PinkPad and CarePad) in restraining subject displacement, for progressively increasing traction loads and different Trendelenburg angles. METHODS: Three healthy male subjects were recruited and tested in supine and Trendelenburg positions (5° and 10°), using a customized boot-pulley system. Ten load disks (5 kg) were dropped at 15s intervals, increasing gradually the traction load up to 50 kg. Pelvis displacement along the traction direction was measured with a motion capture system. The displacement at 50 kg of traction load was analyzed and compared across various pads and bed inclinations. Response to varying traction loads was statistically assessed with a quadratic function model. RESULTS: Pelvis displacement at 50 kg traction load was below 60 mm for all conditions. Comparing PinkPad and CarePad, no significant differences in displacement were observed. Finally, similar displacements were observed for the supine and Trendelenburg positions. CONCLUSIONS: Both PinkPad and CarePad exhibited nearly linear behavior under increasing traction loads, limiting displacement to 60 mm at most for 50 kg loads. Contrary to expectations, placing subjects in the Trendelenburg position did not increase adhesion.

Ganz femoral head reduction associated with coverage and containment procedures improve radiological and functional outcomes in Perthes' disease.

Aims: Ganz's studies made it possible to address joint deformities on both the femoral and acetabular side brought about by Perthes' disease. Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency, along with periacetabular osteotomy (PAO), which may enhance coverage and containment. The purpose of this study is to show the clinical and morphological outcomes of the technique and the use of an implemented planning approach. Methods: From September 2015 to December 2021, 13 FHROs were performed on 11 patients for Perthes' disease in two centres. Of these, 11 hips had an associated PAO. A specific CT- and MRI-based protocol for virtual simulation of the corrections was developed. Outcomes were assessed with radiological parameters (sphericity index, extrusion index, integrity of the Shenton's line, lateral centre-edge angle (LCEA), Tönnis angle), and clinical parameters (range of motion, visual analogue scale (VAS) for pain, Merle d'Aubigné-Postel score, modified Harris Hip Score (mHHS), and EuroQol five-dimension five-level health questionnaire (EQ-5D-5L)). Early and late complications were reported. Results: The mean follow-up was 39.7 months (standard deviation (SD) 26.4). The mean age at surgery was 11.4 years (SD 1.6). No major complications were recorded. One patient required a total hip arthroplasty. Mean femoral head sphericity increased from 46.8% (SD 9.34%) to 70.2% (SD 15.44; p < 0.001); mean LCEA from 19.2° (SD 9.03°) to 44° (SD 10.27°; p < 0.001); mean extrusion index from 37.8 (SD 8.70) to 7.5 (SD 9.28; p < 0.001); and mean Tönnis angle from 16.5° (SD 12.35°) to 4.8° (SD 4.05°; p = 0.100). The mean VAS improved from 3.55 (SD 3.05) to 1.22 (1.72; p = 0.06); mean Merle d'Aubigné-Postel score from 14.55 (SD 1.74) to 16 (SD 1.6; p = 0.01); and mean mHHS from 60.6 (SD 18.06) to 81 (SD 6.63; p = 0.021). The EQ-5D-5L also showed significant improvements. Conclusion: FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical, and morphological outcomes in Perthes' disease. The newly introduced simulation and planning algorithm may help to further refine the technique.

Proximal femoral valgus osteotomy for the treatment of developmental coxa vara: a systematic review of the literature.

Background: Developmental Coxa Vara (DCV) consists on a pathological reduction in head-shaft angle (HSA) and increased femoral retroversion. Several case series reported outcomes on proximal femoral valgus osteotomy (PFVO), but no evidence synthesis had been conducted. This systematic review aimed to (1) analyze success rate and complications, (2) report the degree of correction according to the HSA and the Hilgenreiner Epiphyseal Angle (HEA), compare success rate and degree of correction of subtrochanteric (SVO) vs intertrochanteric (IVO) osteotomy, and (4) difference in success rate and correction between patients in which an internal (IF) or external fixation (EF) technique was used. Methods: Four databases (PubMed, Scopus, Embase, and Cochrane Database of Systematic Reviews) were searched until February 20th, 2024 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies presenting outcomes on PFVO for DCV with >2 years follow-up and >5 patients were included. Review articles, language other than English and coxa vara secondary to other conditions were excluded. Study quality was evaluated through MINORS criteria. Results: 10 case series (level of evidence IV) were located for a total of 153 patients and 192 hips. Baseline results were as follows: male/female ratio was 1.45, mean age at surgery was 6.7 ± 1.5 and follow-up 5.1 ± 5.5 years. Overall success rate was 88.8%, with failure considered as any indication to revision surgery. Complications included loss of correction (10.9%), deep (1.0%) or superficial wound infection (2.6%). Revision surgery was performed in 18 hips (9.4%). Average correction was measured through HSA (preoperative 94.6 ± 8.1, postoperative 134.4 ± 10.2, change 38.2 ± 7.5°, p < 0.001) and HEA (preoperative 71.9 ± 5.5, postoperative 31.7 ± 5.7°, change 33.7 ± 10.5°, p < 0.001). Success rate was similar between osteotomy techniques (SVO: 91.0%; IVO: 94.1%; p = 0.48) and fixation strategy (IF: 85.4%; EF 95.8%; p = 0.096). Conclusions: PFVO presented satisfactory results for the treatment of DCV, with similar outcomes concerning the osteotomy site and fixation technique used. HSA and HEA correction were correlated to PFVO success rate. However, coxa vara is a tridimensional deformity, thus other parameters such as posterior sloping angle, mechanical axial deviation and proximal femoral offset should be included in future studies.

Vision Transformer for femur fracture classification.

INTRODUCTION: In recent years, the scientific community focused on developing Computer-Aided Diagnosis (CAD) tools that could improve clinicians' bone fractures diagnosis, primarily based on Convolutional Neural Networks (CNNs). However, the discerning accuracy of fractures' subtypes was far from optimal. The aim of the study was 1) to evaluate a new CAD system based on Vision Transformers (ViT), a very recent and powerful deep learning technique, and 2) to assess whether clinicians' diagnostic accuracy could be improved using this system. MATERIALS AND METHODS: 4207 manually annotated images were used and distributed, by following the AO/OTA classification, in different fracture types. The ViT architecture was used and compared with a classic CNN and a multistage architecture composed of successive CNNs. To demonstrate the reliability of this approach, (1) the attention maps were used to visualize the most relevant areas of the images, (2) the performance of a generic CNN and ViT was compared through unsupervised learning techniques, and (3) 11 clinicians were asked to evaluate and classify 150 proximal femur fractures' images with and without the help of the ViT, then results were compared for potential improvement. RESULTS: The ViT was able to predict 83% of the test images correctly. Precision, recall and F1-score were 0.77 (CI 0.64-0.90), 0.76 (CI 0.62-0.91) and 0.77 (CI 0.64-0.89), respectively. The clinicians' diagnostic improvement was 29% (accuracy 97%; p 0.003) when supported by ViT's predictions, outperforming the algorithm alone. CONCLUSIONS: This paper showed the potential of Vision Transformers in bone fracture classification. For the first time, good results were obtained in sub-fractures classification, outperforming the state of the art. Accordingly, the assisted diagnosis yielded the best results, proving the effectiveness of collaborative work between neural networks and clinicians.

Hierarchical fracture classification of proximal femur X-Ray images using a multistage Deep Learning approach.

PURPOSE: Suspected fractures are among the most common reasons for patients to visit emergency departments and often can be difficult to detect and analyze them on film scans. Therefore, we aimed to design a Deep Learning-based tool able to help doctors in diagnosis of bone fractures, following the hierarchical classification proposed by the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Foundation and the Orthopaedic Trauma Association (OTA). METHODS: 2453 manually annotated images of proximal femur were used for the classification in different fracture types (1133 Unbroken femur, 570 type A, 750 type B). Secondly, the A type fractures were further classified into the types A1, A2, A3. Two approaches were implemented: the first is a fine-tuned InceptionV3 convolutional neural network (CNN), used as a baseline for our own proposed approach; the second is a multistage architecture composed by successive CNNs in cascade, perfectly suited to the hierarchical structure of the AO/OTA classification. Gradient Class Activation Maps (Grad-CAM) where used to visualize the most relevant areas of the images for classification. The averaged ability of the CNN was measured with accuracy, area under receiver operating characteristics curve (AUC), recall, precision and F1-score. The averaged ability of the orthopedists with and without the help of the CNN was measured with accuracy and Cohen's Kappa coefficient. RESULTS: We obtained an averaged accuracy of 0.86 (CI 0.84-0.88) for three classes classification and 0.81 (CI 0.79-0.82) for five classes classification. The average accuracy improvement of specialists was 14 % with and without the CAD (Computer Assisted Diagnosis) system. CONCLUSION: We showed the potential of using a CAD system based on CNN for improving diagnosis accuracy and for helping students with a lower level of expertise. We started our work with proximal femur fractures and we aim to extend it to all bone segments further in the future, in order to implement a tool that could be used in every-day hospital routine.

A pectin-honey hydrogel prevents postoperative intraperitoneal adhesions in a rat model.

BACKGROUND: Adhesions are a common postoperative surgical complication. Liquid honey has been used intraperitoneally to reduce the incidence of these adhesions. However, solid barriers are considered more effective than liquids in decreasing postoperative intra-abdominal adhesion formation; therefore, a new pectin-honey hydrogel (PHH) was produced and its effectiveness was evaluated in a rat cecal abrasion model. Standardized cecal/peritoneal abrasion was performed through laparotomy in 48 adult Sprague-Dawley rats to induce peritoneal adhesion formation. Rats were randomly assigned to a control (C) and treatment (T) group. In group T, PHHs were placed between the injured peritoneum and cecum. Animals were euthanized on day 15 after surgery. Adhesions were evaluated macroscopically and adhesion scores were recorded and compared between the two groups. Inflammation, fibrosis, and neovascularization were histologically graded and compared between the groups. RESULTS: In group C, 17 of 24 (70.8%) animals developed adhesions between the cecum and peritoneum, while in group T only 5 of 24 (20.8%) did (p = 0.0012). In group C, one rat had an adhesion score of 3, sixteen had scores of 2, and seven rats had scores of 0. In group T, four rats had adhesion scores of 2, one rat had an adhesion score of 1 and nineteen have score 0 (p = 0.0003). Significantly lower grades of inflammation, fibrosis, and neovascularization were seen in group T (p = 0.006, p = 0.001, p = 0.002, respectively). CONCLUSION: PHH is a novel absorbable barrier that is effective in preventing intra-abdominal adhesions in a cecal abrasion model in rats.