Intermediate-Term Outcome of 3-Dimensional Corrective Osteotomy for Malunited Distal Radius Fractures With a Mean Follow-Up of 6 Years.

PURPOSE: Our study aimed to analyze the functional and radiological intermediate-term outcome of 3-dimensional-guided corrective osteotomies for malunited distal radius fractures and to evaluate the progression of osteoarthritis after this intervention. METHODS: All patients with malunited distal radius fractures who underwent 3-dimensional-guided corrective osteotomies from October 2008 to January 2015 were included. Pre- and postoperative range of motion, grip strength, and postoperative patient-reported outcomes were assessed. Pre- and postoperative osteoarthritis grading was performed using conventional radiographs and the osteoarthritis grading system described by Knirk and Jupiter. Additionally, the evaluation of articular stepoff was performed using pre- and postoperative computed tomography. RESULTS: Fifteen patients, with a mean follow-up of 6 years (range, 4.1-10.4 years), were included. According to rater 1, 8 cases had no postoperative osteoarthritis progression, 6 cases had progression of 1 grade, and 1 case had progression of 2 grades. According to rater 2, there was no progression in 11 cases, and there was progression of 1 grade in 2 cases and progression of 2 grades in 2 cases. Compared with before the surgery, the patients demonstrated a mean improvement of 14.8 kg (±12.6 kg) in grip strength after the surgery. At the last follow-up, the mean Patient-Rated Wrist Evaluation score was 11.8 (±12.0), the mean Disabilities of the Arm, Shoulder and Hand score was 11.1 (±11.4), and the mean residual pain score on the visual analog scale was 0.8 (±1.0). CONCLUSIONS: The intermediate-term outcome of 3-dimensional-guided corrective osteotomies for distal radius intra-articular malunions showed excellent patient-reported outcomes and no clinically relevant progression of osteoarthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Three-Dimensionally Planned and Printed Patient-Tailored Plates for Corrective Osteotomies of the Distal Radius and Forearm.

PURPOSE: We evaluated the 1-year postoperative clinical and patient-reported outcomes in patients who had a 3-dimensional planned corrective osteotomy of their distal radius, radial shaft, or ulnar shaft using a printed, anatomical, patient-tailored plate to determine the feasibility and effectiveness of this methodology. METHODS: Simulations in computer-assisted preoperative planning of corrective osteotomies resulted in 3-dimensionally printed surgical guides, surgical models, and anatomically customized plates for application at the distal radius and forearm. Patients with malunions of the distal radius or forearm who underwent fixation with the custom-made plates were documented in our registry. Grip strength and range of motion assessments were made before surgery (baseline), as well as at 6 weeks and 3 and 12 months. Additionally, patients rated their wrist-related pain and disability using the Patient-Rated Wrist Evaluation. RESULTS: Fifteen patients underwent corrective surgery, and the 1-year follow-up data of 14 patients with a median age of 56 years (interquartile range, 24-64 years) were available for analysis. The median baseline Patient-Rated Wrist Evaluation score improved from 47 to 7 after 1 year. The flexion-extension arc of motion of the wrist increased from 90° at baseline to 130° at 1 year and the pronation-supination arc of motion of the wrist increased from 135° to 160° in the same time period. Differences in radiological measurements for palmar and radial inclinations, as well as for ulnar variance between the affected and contralateral wrists, were reduced with the osteotomy. In 1 case, the plate was removed 11 months after the osteotomy. No severe adverse events were reported. CONCLUSIONS: Three-dimensionally planned and printed patient-tailored plates offer a reliable method for correcting even complex malunions of the distal radius and forearm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Three-Dimensional Automated Assessment of the Distal Radioulnar Joint Morphology According to Sigmoid Notch Surface Orientation.

PURPOSE: To develop reproducible 3-dimensional measurements for quantification of the distal radioulnar joint (DRUJ) morphology. We hypothesized that automated 3-dimensional measurement of the ulnar variance (UV) and the sigmoid notch (SN) angle would be comparable to those of the reference standard while overcoming some drawbacks of conventional 2-dimensional measurements. METHODS: Radiological data of healthy forearm bones (radiographs and computed tomography) of 53 adult subjects were included in the study. Automated measurements were developed for assessment of the SN morphology based on 3-dimensional landmarks, incorporating subject-specific estimation of cartilage surface orientation. A common anatomical reference was defined among the different imaging modalities and a comparison of the SN angle and UV measurements was performed in radiographs, computed tomography scans, and 3-dimensional models. Finally, the 3-dimensional UV measurements were evaluated in an experimental setup using 3-dimensional printed bone models. RESULTS: The automated 3-dimensional measurements of SN subtypes showed a notably larger notch radius (18.9 mm) for negative SN angles compared with positive SN angles in subjects (16.9 mm). Similar UV measurements were obtained in healthy DRUJ morphologies, with a high correlation between radiographs and 3-dimensional measurements for the SN angle (0.77) and UV (0.85). In the experimental setup with pathological radial inclinations, UV was on average 1.13 mm larger in the radiographs compared with the 3-dimensional measurements, and 1.30 mm larger in the cases with pathological palmar tilts. Furthermore, UV radiograph measurements on the modified palmar tilt deviated from the 3-dimensional measurements. CONCLUSIONS: The developed 3-dimensional automated measurements were able to quantify morphological differences among sigmoid notch subtypes and were comparable to those of the reference standard. CLINICAL RELEVANCE: The developed methods do not depend on the forearm position or orientation of the distal radius and can be used for 3-dimensional quantification of DRUJ pathologies in 3-dimensional surgical planning.

Corrective Osteotomy for Malunited Diaphyseal Forearm Fractures Using Preoperative 3-Dimensional Planning and Patient-Specific Surgical Guides and Implants.

PURPOSE: Three-dimensional planning based on computed tomography images of the malunited and the mirrored contralateral forearm allows preoperative simulations of corrective osteotomies, the fabrication of patient-specific osteotomy guides, and custom-made 3-dimensional printed titanium plates. This study aims to assess the precision and clinical outcome of this technique. METHODS: This was a prospective pilot study with 5 consecutive patients. The mean age at initial injury was 11 years (range, 4-16 years), and the mean interval from the time of injury to the time of corrective surgery was 32 months (range, 7-107 months). Patient-specific osteotomy guides and custom-made plates were used for multiplanar corrective osteotomies of both forearm bones at the distal level in 1 patient and at the middle-third level in 4 patients. Patients were assessed before and after surgery after a mean follow-up of 42 months (range, 29-51 months). RESULTS: The mean planned angular corrections of the ulna and radius before surgery were 9.9° and 10.0°, respectively. The mean postoperative corrections obtained were 10.1° and 10.8° with corresponding mean errors in correction of 1.8° (range, 0.3°-5.2°) for the ulna and 1.4° (range, 0.2°-3.3°) for the radius. Forearm supination improved significantly from 47° (range, 25°-75°) before surgery to 89° (range, 85°-90°) at final review. Forearm pronation improved from 68° (range, 45°-84°) to 87° (range, 82°-90°). In addition, there was a statistically significant improvement in pain and grip strength. CONCLUSIONS: This study demonstrates that 3-dimensional planned patient-specific guides and implants allow the surgeon to perform precise corrective osteotomies of complex multiplanar forearm deformities with satisfactory preliminary results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Computer-Assisted 3-Dimensional Reconstructions of Scaphoid Fractures and Nonunions With and Without the Use of Patient-Specific Guides: Early Clinical Outcomes and Postoperative Assessments of Reconstruction Accuracy.

PURPOSE: To present results regarding the accuracy of the reduction of surgically reconstructed scaphoid nonunions or fractures using 3-dimensional computer-based planning with and without patient-specific guides. METHODS: Computer-based surgical planning was performed with computed tomography (CT) data on 22 patients comparing models of the pathological and the opposite uninjured scaphoid in 3 dimensions. For group 1 (9 patients), patient-specific guides were designed and manufactured using additive manufacturing technology. During surgery, the guides were used to define the orientation of the reduced fragments. The scaphoids in group 2 (13 patients) were reduced with the conventional freehand technique. All scaphoids in both groups were fixed with a headless compression screw or K-wires, and all bone defects (except one) were filled with autologous bone grafts or vascularized grafts. Postoperative CT scans were acquired 2 or more months after the operations to monitor consolidation and compare the final result with the preoperative plan. The clinical results and accuracy of the reconstructions were compared. RESULTS: In group 1, 8 of 9 scaphoids healed after 2 to 6 months, and partial nonunion after 9 months was observed in one patient. In group 2, 11 of 13 scaphoids healed between 2 and 34 months whereas 2 scaphoids did not consolidate. Comparison of the preoperative and postoperative 3-dimensional data revealed an average residual displacement of 7° (4° in flexion-extension, 4° in ulnar-radial deviation, and 3° in pronation-supination) in group 1. In group 2, residual displacement after surgery was 26° (22° in flexion-extension, 12° in ulnar-radial deviation, and 7° in pronation-supination). The difference in the accuracy of reconstruction was significant. CONCLUSIONS: Although the scaphoid is small, patient-specific guides can be used to perform scaphoid reconstructions. When the guides were used, the reconstructions were significantly more anatomic compared with those resulting from the freehand technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Pediatric Forearm Malunions.

The aim of this article is to review the evaluation and management of pediatric forearm malunions. Acceptable parameters for nonoperative management of pediatric forearm fractures are reviewed, followed by clinical and imaging workups of malunions and decision-making points for treatment. The landscape of available technology for planning and execution of corrective osteotomy is discussed. Several cases of pediatric forearm malunion are presented, along with surgical and functional outcomes. Recommendations are given regarding the authors' preferred approach for management of pediatric forearm malunions.

Understanding economic analysis and cost-effectiveness of CT scan-guided, 3-dimensional, robotic-arm assisted lower extremity arthroplasty: a systematic review.

Aim: The overall goal of this review was to examine the cost-utility of robotic-arm assisted surgery versus manual surgery. Methods: We performed a systematic review of all health economic studies that compared CT-based robotic-arm assisted unicompartmental knee arthroplasty, total knee arthroplasty and total hip arthroplasty with manual techniques. The papers selected focused on various cost-utility measures. In addition, where appropriate, secondary aims encompassed various clinical outcomes (e.g., readmissions, discharges to subacute care, etc.). Only articles directly comparing CT-based robotic-arm assisted joint arthroplasty with manual joint arthroplasty were included, for a resulting total of 21 reports. Results: Almost all twenty-one studies demonstrated a positive effect of CT scan-guided robotic-assisted joint arthroplasty on health economic outcomes. For studies reporting on 90-day episodes of costs, 10 out of 12 found lower costs in the robotic-arm assisted groups. Conclusion: Robotic-arm assisted joint arthroplasty patients had shorter lengths of stay and cost savings based on their 90-day episodes of care, among other metrics. Payors would likely benefit from encouraging the use of this CT-based robotic technology.

Three-dimensional correction of distal radius intra-articular malunions using patient-specific drill guides.

PURPOSE: To analyze the feasibility of combining computer-assisted 3-dimensional planning with patient-specific drill guides and to evaluate this technology's surgical outcomes for distal radius intra-articular malunions. METHODS: Six symptomatic patients with intra-articular malunions of the distal radius with a stepoff of more than 2 mm were treated with an outside-in corrective osteotomy. The described cases consist of 2 malunited volar Barton fractures, 2 radial styloid fractures, 1 AO-type C1 fracture, and 1 die-punch fracture. The osteotomies were guided by 3-dimensionally generated aiming guides that allowed precise cutting and the reduction of up to 2 fragments. All 6 patients were examined clinically and radiologically after 1 year. The surgical outcomes were quantitatively analyzed by comparing the preoperative and postoperative computed tomographic data. RESULTS: In all 6 cases, the osteotomies were consolidated 8 weeks postoperatively. After 1 year, 4 patients were pain-free, 1 had mild pain, and 1 experienced moderate pain during heavy work. Wrist motion and grip strength were improved in all patients. The postoperative radiographs showed no articular stepoff or degenerative changes. CONCLUSIONS: Patient-specific aiming guides provided a reliable method to correct intra-articular malunions of the distal radius. This technique allows the surgeon to safely perform difficult intra-articular osteotomies and may help limit the need for salvage procedures such as partial or complete wrist arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Time benefits of 3D planning in orthognathic surgery: a systematic review.

This systematic review aimed to evaluate the possible time benefits when using 3-dimensional (3D) planning prior to orthognathic surgery compared with a conventional method alone. The databases utilised were PubMed, Medline, Web of Science, and the Cochrane Library. Studies were selected based on eligibility criteria and reviewed independently by two authors. A total of eight studies were included. The review concludes that there are a limited number of studies with the appropriate experimental protocols in place. Therefore, although there is low-grade evidence to suggest that 3D planning in orthognathic surgery is more time-efficient, the field would benefit from the publication of more rigorous studies.