Pubo-femoral distance in selective ultrasound screening of developmental dysplasia of the hip.

BACKGROUND: Developmental dysplasia of the hip (DDH) incidence is already debated due to different types of screening techniques. Despite of that, timely treatment of this pathology is necessary to reduce complications on the hip joint. METHODS: A retrospective study has been performed on the incidence of DDH in Marche region (Italy) in 2017. Epidemiological data have been collected and evaluated. 302 ultrasound images stored in the hospital archives were selected to measure pubo-femoral distance (PFD) and bony rim percentage (BRP). PFD and BRP values were compared with α and ß angles measured by Graf method. RESULTS: DDH incidence was 12%. Girls were more affected than males (ratio 3:1). Right side was more involved, 20% of patient had familiarity with DDH, 7% were breech babies and 15% suffered from other congenital orthopedic diseases. PFD in pathological hips was 3.21 mm (0.60-7 mm) and 2.47 mm (0.80-5.30 mm) in normal hips (P<0.005). Dispersion of PFD with respect to α and ß angles showed that PFD grows with increasing ß angle values and decreasing α angles. BRP in pathological hips was 47.29%, while in normal hips was 49.53% (<3 months). BRP was 49.71% in normal hips and 45.83% in pathological ones (>3 months). BRP measurement did not match the expected results, requiring more studies before its adoption in clinical practice. CONCLUSIONS: Our study evidenced the DDH incidence in Marche region and helped to validate a new screening technique consisting in measuring of PFD. For a full BRP validation, future studies will still be required.

Case series of four complex spinal deformities: new frontiers in pre-operative planning.

BACKGROUND AND AIM: Osseous and medullar anomalies constitute a hard challenge for interpretation of complex vertebral deformities anatomy. To better frame these deformities three-Dimensional (3D) printing represents a new frontier in this field. The aim of this brief report is describing the use of 3D printed models for surgical planning in four complex vertebral deformity cases treatment. METHODS: Four cases of severe scoliosis were treated between December 2017 and January 2019; patients' mean age was 12,25 years. Two patients underwent neurosurgical intervention for myelomeningocele at the time of birth. Standard and dynamics X-Ray, Computed Tomography (CT) and Magnetic Resonance (MR) of the column were performed pre-operatively. CT files were implemented to build the 3D model of each spine and selected ribs. The models were 3D printed in thermoplastic material, then used to study the deformities and for surgical planning. A survey proposal about 3D models' utility and accuracy has been made to 15 residents and 6 main surgeons. RESULTS: Preparation of each 3D models required about 316.5 minutes and printing time was about 108 hours each. The average cost was 183.16 € to produce one 3D printed model, which resulted useful in surgical planning and educational. CONCLUSIONS: The manufacture of 3D models requires time, resources and multidisciplinary approach, it must be justified by complexity of the case. In this study 3D Printing allowed surgeons to carefully plan and simulate the surgery, ensuring for a better sizing of the implant.

Comparison of Three 3D Segmentation Software Tools for Hip Surgical Planning.

In hip arthroplasty, preoperative planning is fundamental to reaching a successful surgery. Nowadays, several software tools for computed tomography (CT) image processing are available. However, research studies comparing segmentation tools for hip surgery planning for patients affected by osteoarthritic diseases or osteoporotic fractures are still lacking. The present work compares three different software from the geometric, dimensional, and usability perspectives to identify the best three-dimensional (3D) modelling tool for the reconstruction of pathological femoral heads. Syngo.via Frontier (by Siemens Healthcare) is a medical image reading and post-processing software that allows low-skilled operators to produce prototypes. Materialise (by Mimics) is a commercial medical modelling software. 3D Slicer (by slicer.org) is an open-source development platform used in medical and biomedical fields. The 3D models reconstructed starting from the in vivo CT images of the pathological femoral head are compared with the geometries obtained from the laser scan of the in vitro bony specimens. The results show that Mimics and 3D Slicer are better for dimensional and geometric accuracy in the 3D reconstruction, while syngo.via Frontier is the easiest to use in the hospital setting.

The use of 3D printed models for the pre-operative planning of surgical correction of pediatric hip deformities: a case series and concise review of the literature.

BACKGROUND AND AIM: Three-dimensional (3D) printing is prevailing in surgical planning of complex cases. The aim of this study is to describe the use of 3D printed models during the surgical planning for the treatment of four pediatric hip deformity cases. Moreover, pediatric pelvic deformities analyzed by 3D printed models have been object of a concise review. METHODS: All treated patients were females, with an average age of 5 years old. Patients' dysplastic pelvises were 3D-printed in real scale using processed files from Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). Data about 3D printing, surgery time, blood loss and fluoroscopy have been recorded. RESULTS: The Zanoli-Pemberton or Ganz-Paley osteotomies were performed on the four 3D printed models, then the real surgery was performed in the operating room. Time and costs to produce 3D printed models were respectively on average 17:26 h and 34.66 €. The surgical duration took about 87.5 min while the blood loss average was 1.9 ml/dl. Fluoroscopy time was 21 sec. MRI model resulted inaccurate and more difficult to produce. 10 papers have been selected for the concise literature review. CONCLUSIONS: 3D printed models have proved themselves useful in the reduction of surgery time, blood loss and ionizing radiation, as well as they have improved surgical outcomes. 3D printed model is a valid tool to deepen the complex anatomy and orientate surgical choices by allowing surgeons to carefully plan the surgery.

Assessing 3-D Printing in Hip Replacement Surgical Planning.

PURPOSE: To evaluate the accuracy of 3-D printed models of the femoral head based on preoperative computed tomography (CT) images. Other goals were to compare the cartilage thickness of bony specimen to the printed models and calculate the standard deviation between 3-D printed models based on CT images and laser scan models. METHODS: This retrospective study analyzed 10 patients who underwent preoperative CT imaging and hip replacement. Preoperative femoral head 3-D printed models were produced from CT images. Bony specimens were collected from surgical operations and scanned using CT and 3-D laser scanning, and cartilage thickness subsequently was measured by histological analysis. Comparisons of printed models based on CT images and printed models based on 3-D laser scanning were performed by overlapping their external surfaces using dedicated software and the standard deviation was calculated. RESULTS: The average standard deviation between the bony specimen 3-D models and preoperative 3-D printed CT femoral head models was 0.651 mm. The cartilage was approximately 1.487 mm thick. DISCUSSION: The comparison between preoperative CT image-based 3-D models and the postoperative bony specimen-based models permitted evaluation of the accuracy of preoperative CT image-based 3-D printed models. Cartilage thickness was estimated indirectly by comparing models obtained by CT and laser scanning, and it was related to the calculated standard deviation to overcome the cartilage detection limit of CT. This study shows how each step can generate accuracy errors on the final 3-D printed model. A repeatable and sustainable workflow for creating accurate and reproducible 3-D printed models could overcome this issue. Moreover, orthopedic surgeons should be aware of 3-D printed model precision in clinical practice. CONCLUSIONS: This study provides encouraging results on the accuracy of 3-D printed models for surgical planning.

Remodeling of distal radius fractures in children: preliminary retrospective cost/analysis in level II pediatric trauma center.

BACKGROUND AND AIM: Children displaced distal radius fractures (DRFs) are commonly treated by reduction. Yet, their excellent remodeling ability provides good clinical-radiographic outcomes even in case of non-anatomical reduction. The reduction under analgesia or sedation involves hospitalizations, greater risks, and higher hospital costs. The aim of this preliminary study is to demonstrate the accountability and conveniency of non-anatomical reduction. METHODS: The study involved all 0-8 years-old children who were affected by a closed overriding DRF from February 2017 to December 2018 and were managed non-operatively by a long arm cast without reduction, analgesia, or sedation treatments. We retrospectively evaluated their clinical-radiographic outcomes and healing time. The costs of no-reduction treatments were compared with those of the two main approaches to DRFs, that is: closed reduction under sedation and application of a long arm cast; closed reduction under anesthesia, percutaneous pinning, and application of a long arm cast. The comparison was based on the Diagnosis Related Group system. RESULTS: We treated 11 children with an average initial radial shortening of 5±3 mm and average initial sagittal and coronal angulations of 4.0° and 3.5°, respectively. Average casting duration was 40 days. All patients achieved a full range of wrist motion without deformities. The procedure was respectively 7 times less expensive than closed reduction in emergency room under sedation and application of a long arm cast, and 64 times less expensive than closed reduction in the operating room under anesthesia, percutaneous pinning, and application of a long arm cast. CONCLUSIONS: In children aged 0-8 years, non-operative treatment of closed overriding DRFs with a long arm cast without reduction is a simple and cost-effective procedure with both clinical and radiographic medium-term excellent outcomes.

A Peculiar Case of Open Complex Elbow Injury with Critical Bone Loss, Triceps Reinsertion, and Scar Tissue might Provide for Elbow Stability?

BACKGROUND: Complex elbow injuries (CEIs) are severe and rare lesions, difficult to treat correctly due to the different patterns of clinical presentations. Standard methods cannot often be applied. The main goals of the treatment are performing a stable osteosynthesis of all fractures, obtaining a concentric and stable reduction of the elbow by repairing the soft tissue constraint lesions, and allowing early motion. Since the introduction of virtual reality (VR) approaches in clinical practice, three-dimensional (3D) computed tomography (CT) and 3D printing have revolutionised orthopaedic surgeries, thus helping to understand the anatomy and the pathology of complex cases. CASE DESCRIPTION: We discussed a case of CEI, characterised by an extended soft tissue (IIIB Gustilo classification) and neurovascular lesions associated with bone loss in a young female patient. Olecranon fracture was type IIIB according to Mayo classification. We outlined the steps of a pluri-tissue reconstructive approach and stressed the importance of 3D printing in the preoperative planning for such cases. Finally, peculiar final functional patient outcomes were reported. CONCLUSION: In this case, we found out that triceps reinsertion and scar process may provide for the joint stability in a low-demanding patient. 3D printing and VR approaches in clinical practice can be useful in the management of CEIs associated with an important bone and soft tissue loss. HOW TO CITE THIS ARTICLE: Facco G, Politano R, Marchesini A, et al. A Peculiar Case of Open Complex Elbow Injury with Critical Bone Loss, Triceps Reinsertion, and Scar Tissue might Provide for Elbow Stability? Strategies Trauma Limb Reconstr 2021;16(1):53-59.

Percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fractures in children.

PURPOSE: To describe clinical and radiographic outcomes after surgical management of angulated radial neck fracture in children. METHODS: Twenty children (aged 2-11 years) with angulated radial neck fracture with more than 30° angulations (Judet type III and IV fractures) were retrospectively reviewed. All the enrolled patients were surgically treated with percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation. Clinical outcomes were evaluated using Tibone and Stoltz score and the Mayo Elbow Performance Score (MEPS). Radiographic outcomes were evaluated with Métaizeau score. Complications were also evaluated. RESULTS: At a mean follow-up of 20 months, no patients showed axial deformity of the upper limb or instability of the elbow. The mean value of the MEPS was 99.2, and excellent clinical results were achieved in 14 patients (73.7%) at Tibone and Stoltz score. The final X-rays showed fracture healing in all patients; furthermore, 75% of patients showed excellent reduction at Métaizeau score. No patient developed complication. There were no iatrogenic nerve injuries or pin infections. CONCLUSIONS: The results demonstrate that percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fracture treatment is a simple, effective, rapid and inexpensive procedure. LEVEL OF EVIDENCE: IV (case series and systematic review of level IV studies).