Enhancing precision in osteochondral lesions of the talus measurements and improving agreement in surgical decision-making using weight-bearing computed tomography and distance mapping.

PURPOSE: Weight-bearing computed tomography (WBCT) enables the creation of a three-dimensional (3D) model that represents the ankle morphology in a standing position. Distance mapping (DM) is a complementary feature that uses color coding to represent the relative intraarticular distance and can be used to outline intraarticular defects. Consequently, DM offers a novel approach to delineating osteochondral lesions of the talus (OLT), allowing for the quantification of its surface, volume and depth. The reliability of DM for OLT measurements has yet to be thoroughly evaluated. This study primarily aims to determine the reliability of DM in measuring the surface, depth and volume of OLT. A secondary objective is to ascertain whether measurements obtained through DM, when integrated with a predefined treatment algorithm, can facilitate consensus among surgeons regarding the optimal surgical intervention. METHODS: This cohort comprised 36 patients with 40 OLTs evaluated using WBCT and DM. Two raters used DM to determine the lesion boundary (LB) and lesion fundus (LF) and calculate the lesion depth, surface and volume. The raters were asked to choose between bone marrow stimulation, autologous matrix-induced chondrogenesis and osteochondral transposition based on the measurement. Inter-rater and intra-rater agreement was measured. RESULTS: Interclass correlation of the lesion's depth surface produced an excellent inter-rater and intra-rater agreement of 0.90-0.94 p < 0.001. Cohen's κ agreement analysis of the preferable preoperative plan produced a κ = 0.834, p < 0.001, indicating a near-perfect agreement. CONCLUSION: WBCT-based 3D modules and DM can be used to measure the lesion's surface, depth and volume with excellent inter-rater and inter-rater agreement; using this measurement and a predetermined treatment algorithm, a near-perfect inter-rater agreement for the preoperative planning was reached. WBCT in conjunction with AI capabilities could help determine the type of surgery needed preoperatively, evaluate the hindfoot alignment and assess if additional surgeries are needed. LEVEL OF EVIDENCE: Level III.

MRI-based navigated cryosurgery of extra-abdominal desmoid tumors using skin fiducial markers: a case series of 15 cases.

BACKGROUND: Precision surgery is becoming increasingly important in the field of Orthopaedic Oncology. Image-guided percutaneous cryosurgery (CRA) has emerged as a valid treatment modality for extra-abdominal desmoid tumors (EDTs). To date, most CRA procedures use CT-based guidance which fails to properly characterize tumor segments. Computer-guided MRI navigation can address this issue however, the lack of a fixed landmark for registration remains a challenge. Successful CRA correlates directly with precision approaches facilitated by intraoperative imaging guidance. This is the first study that attempts to assess the feasibility and efficacy of a novel approach of using skin fiducial markers to overcome the challenge of a MRI-based navigation CRA for symptomatic or progressive EDTs. METHODS: In this retrospective study conducted between 2018 and 2020, 11 patients at a single center with symptomatic or progressive EDTs were treated with CRA using intraoperative MRI navigation. Fifteen cryosurgery procedures were performed, each adhering to a personalized pre-operative plan. Total tumor size, viable and non-viable portions pre- and post-operation, and SF-36 questionnaire evaluating subjective health were recorded. RESULTS: All CRAs demonstrated 100% adherence to the predetermined plan. Overall, tumor size decreased Median= -56.9% [-25.6, -72.4]) with a reduction in viable tissue, (Median= -80.4% [-53.3, -95.2]). Four patients required additional CRAs. Only one patient's tumor did not reduce in size. One patient suffered from local muscle necrosis. Pre-operation, the average physical and mental scores 41.6 [29.4, 43] and 26.3 [17.6, 40.9] respectively. Post-operation, the average physical and mental scores were 53.4[38, 59.7] and 38 [31.2, 52.7] respectively. CONCLUSION: These findings provide an early indication of the feasibility and efficacy of performing percutaneous cryosurgery using skin fiducial marker registration for MRI-computed navigation to treat EDTs safely. Larger cohorts and multicenter evaluations are needed to determine the efficacy of this technique.

Intraoperative three-dimensional navigation for surgical treatment of osteoid osteoma in the upper extremity: A series of 19 cases.

The surgical treatment for osteoid osteoma (OO) in the upper extremity is challenging due to the difficulty in locating the lesion and the crowding of sensitive structures within the anatomy. This study aimed to describe the outcomes of navigated minimally invasive radiofrequency ablation and those of navigated mini open-intralesional curettage in treating these lesions. Nineteen consecutive patients with OO in the upper limb who underwent navigated surgery were included. The average QuickDASH and Numeric Pain Rating Scale improved from 62.2 ± 23.7 to 11.7 ± 16.9 and from 8.1 ± 1.6 to 0.5 ± 1.8, respectively (p < .01 each) following the procedure. Two complications were recorded: one patient had persistent radial nerve palsy, and one patient had transient partial radial nerve weakness. In conclusion, navigation is an important tool in the surgical treatment of OO in the upper limb. A mini open approach to identify and protect neurovascular structures is recommended.

Favorable outcomes of navigated percutaneous ablation and cementoplasty of bone metastasis in the extremities and pelvis-a case series of 13 cases.

OBJECTIVES: Palliative treatment options for bone metastasis are limited, especially in cases where standard protocols have already failed. The purpose of this study was to evaluate the efficacy and safety of percutaneous ablation, either by cryoablation or radiofrequency, combined with percutaneous cementoplasty using cone-beam guided navigation. The objective was to relieve symptoms and improve functionality in patients suffering from pain secondary to bone metastases, as well as evaluate local disease progression post ablation. METHODS: We conducted a retrospective study of 13 patients (average age 63.6 ± 9.8, nine females) with symptomatic skeletal metastases treated using 3D imaging with navigation and followed for at least 12 months. The treatment protocol was implemented either after failure of first line treatment, or as first line when mechanical instability was present. Percutaneous lesion ablation was performed along with percutaneous cementation. RESULTS: In this study, we observed a statistically significant decrease in pain. The mean Visual Analog Scale pain score decreased from 7.1 ± 0.4 prior to CRA/RFA to 2.2 ± 0.3 after the procedure (p < 0.001). At the 12-months follow-up, all patients were able to ambulate with no assistance (Eastern Cooperative Oncology Group <2). One minor adverse event (paresthesia) and one major adverse event (drop foot) were resolved at 1 year of follow-up. CONCLUSIONS: Treatment of bone metastasis with RFA and CRA in conjunction with cementoplasty using Cone-beam computed tomography navigation provides patients with significant palliative outcomes and in most cases, local tumor control.

Three-dimensional technologies in presurgical planning of bone surgeries: current evidence and future perspectives.

BACKGROUND: The recent development of three-dimensional (3D) technologies introduces a novel set of opportunities to the medical field in general, and specifically to surgery. The preoperative phase has proven to be a critical factor in surgical success. Utilization of 3D technologies has the potential to improve preoperative planning and overall surgical outcomes. In this narrative review article, the authors describe existing clinical data pertaining to the current use of 3D printing, virtual reality, and augmented reality in the preoperative phase of bone surgery. METHODS: The methodology included keyword-based literature search in PubMed and Google Scholar for original articles published between 2014 and 2022. After excluding studies performed in nonbone surgery disciplines, data from 61 studies of five different surgical disciplines were processed to be included in this narrative review. RESULTS: Among the mentioned technologies, 3D printing is currently the most advanced in terms of clinical use, predominantly creating anatomical models and patient-specific instruments that provide high-quality operative preparation. Virtual reality allows to set a surgical plan and to further simulate the procedure via a 2D screen or head mounted display. Augmented reality is found to be useful for surgical simulation upon 3D printed anatomical models or virtual phantoms. CONCLUSIONS: Overall, 3D technologies are gradually becoming an integral part of a surgeon's preoperative toolbox, allowing for increased surgical accuracy and reduction of operation time, mainly in complex and unique surgical cases. This may eventually lead to improved surgical outcomes, thereby optimizing the personalized surgical approach.

Inter and intra-observer agreement of the 3-dimensional CT based anterior inferior iliac spine classification system shows fair-to-moderate agreement among high volume hip surgeons.

PURPOSE: The purpose of this multicenter, multinational study is to evaluate the agreement level of the Hetsroni's classification system across high-volume hip surgeons who specialize in hip preservation surgeries. METHODS: Four surgeons from three countries reviewed a digital survey that included 93 3D CT images of the hip from 53 patients. The population was composed of individuals who had undergone a pelvis CT scan in a tertiary hospital between 2000 and 2016. Each rater reviewed the images and classified each image according to AIIS subtype I, II, or III. After a minimum of two months, the raters repeated the survey. The inter-rater and intra-rater agreement was then assessed. The kappa values were calculated to determine variability. RESULTS: Inter-rater agreement levels yielded fair agreement for both sessions (Kappa = 0.4, p value < 0.001 in the first and Kappa = 0.27, p value < 0.001 in the second). Inter-rater agreement levels separating non-pathological Type I from pathological Types II and III yielded moderate to fair inter-rater agreement levels (K = 0.47, p value < 0.001 in the first session and k = 0.32, p value < 0.001 in the second). Intra-rater reliability displayed moderate agreement (average K = 0.53). CONCLUSION: The current 3D CT-based AIIS classification system shows fair-to-moderate inter- and intra-rater agreement among high-volume hip surgeons. According to this study, the agreement of the Hetsroni classification system is not able to be sufficiently reproduced. Since accurate classification of the AIIS morphology is imperative in establishing proper treatment for SSI, this classification system there is therefore limited in its clinical value. LEVEL OF EVIDENCE: III.

Internal Hemipelvectomy for primary bone sarcomas using intraoperative patient specific instruments- the next step in limb salvage concept.

BACKGROUND: During pelvic Sarcoma resections, Surgeons often struggle to obtain negative margins while minimizing collateral damage and maintaining limb function. These complications are usually due to the complex anatomy of the pelvis. Here we present an accurate 3D surgical approach, including pre-operative printing of models and intraoperative patient-specific instruments (PSIs) for optimizing pelvic sarcoma resections. METHODS: This single-center retrospective study (N = 11) presents surgical, functional, and oncological outcomes of patients (average age 14.6 +/- 7.6 years, 4 males) who underwent pelvic sarcoma resections using a 3D surgical approach between 2016 and 2021. All patients were followed up for at least 24 months (mean = 38.9 +/- 30.1 months). RESULTS: Our results show promising surgical, oncological, and functional outcomes. Using a 3D approach, 90.9% had negative margins, and 63.6% did not require reconstruction surgery. The average estimated blood loss was 895.45 ± 540.12 cc, and the average surgery time was 3:38 ± 0.05 hours. Our results revealed no long-term complications. Three patients suffered from short-term complications of superficial wound infections. At 24 month follow up 72.7% of patients displayed no evidence of disease. The average Musculoskeletal Tumor Society (MSTS) score at 12 months was 22.81. CONCLUSION: 3D technology enables improved accuracy in tumor resections, allowing for less invasive procedures and tailored reconstruction surgeries, potentially leading to better outcomes in function and morbidity. We believe that this approach will enhance treatments and ease prognosis for patients diagnosed with pelvic sarcoma and will become the standard of care in the future.

Intraoperative three-dimensional navigation for surgical treatment of osteoid osteoma in the foot and ankle - A series of 14 cases.

BACKGROUND: The surgical treatment for osteoid osteoma (OO) in the foot and ankle is challenging. It is difficult to locate the lesion and the anatomy is crowded by sensitive structures. The purpose of this study was to describe the outcomes of navigated mini open-intralesional curettage (NMIC) or navigated minimally invasive radiofrequency ablation (NMRFA) in treating these lesions. METHODS: All patients who underwent surgery for OO in the foot and ankle between 2015 and 2020 were included. O-arm navigation was used in All procedures. The choice of NMIC versus NMRFA was made by the surgeon according to the location of the lesion and its proximity to sensitive anatomic structures. RESULTS: Fourteen patients were included. Ten were operated by NMRFA and 4 by NMIC. All patients' symptoms related to OO resolved following a single procedure. Average AOFAS score increased by 18.7 (P < .001). Three patients had the following complications: pathologic fracture, superficial infection and transient deep peroneal nerve sensory loss. CONCLUSION: Navigated surgical treatment of OO in the foot and ankle is accurate, efficient and safe.

Intercalary and geographic lower limb tumor resections with the use of 3D printed Patient Specific Instruments- when less is more.

Background: Primary bone sarcomas are associated with critically sized bone defects and require complete resection with negative margins. Recent advancements in health care have pioneered novel approaches such as the implementation of 3D surgical technologies. This study presents oncological and functional outcomes following tumor resections of long bones with the use of customized 3D-printed Patient Specific Instruments (PSIs). Methods: This single-center retrospective study is comprised of seventeen patients who underwent either intercalary (N = 12) or geographic (N = 5) resections with various reconstruction methods including allograft (N = 8), vascularized fibula (Capanna) (N = 7), and 3D printed customized titanium implants (N = 2), between the years 2016-2020. All patients were operated on with a 3D surgical workflow, including intraoperative PSIs, and were followed up postoperatively for at least 12 months (average 31.40 ± 12.13 months) to assess oncological and functional outcomes. Results: All patients demonstrated negative surgical margins, apart from one patient who had planned positive margins. Three patients suffered from short-term complications, and three patients underwent revision surgery due to graft non-union or pathological fracture. One patient suffered from local recurrence and underwent above-knee amputation. Three patients suffered from lung metastasis. MSTS at 12-month follow-up was 26.9.±5.87. Conclusion: Customized 3D-printed osteotomy PSIs provide surgeons with a novel tool for optimizing bone resection and reconstruction in long bones surgeries, thus minimizing overall tissue trauma and reducing the risk of damage to nervous and vascular structures. This study demonstrates that the use of PSIs has the potential to improve functional and oncological outcomes. We believe that this technique will become increasingly popular in the future as a widely applicable, highly accurate, cost-effective optimization tool.

In situ cryoablation of sacral Giant Cell Tumor using three-dimensional (3D) model: A case report.

Three-dimensional planning of in-situ (trans-sacral) image guided cryoablation provides a method to treat sacral GCTs that accommodates the intricacies of the pelvis offering a safer, more efficacious alternative. Here we report on IM a 23-year-old female with a sacral GCT. She presented to Tel Aviv Medical Center with ongoing pain as well as neurological symptoms. For six years, the patient was in-and-out of the hospital for Denosumab treatment and recurrent infections. Eventually, further treatment became necessary, and she was treated with image guided cryoablation. By six months follow-up, the patient was mobile and pain-free.