Implementing 3D fluoroscopy in the management of tibial plateau fractures: Shorter hospitalization and decline in revision surgery, but increase in the duration of surgery and radiation exposure.

BACKGROUND: Intraoperative 3D fluoroscopy (3DRX) is increasingly used in fracture management instead of conventional fluoroscopy (RX), but its effect on the treatment and outcome of tibial plateau fractures (TFs) is not well known. This study aims to evaluate whether the use of 3DRX in the treatment of tibial plateau fractures reduces the number of revision surgeries. METHODS: This retrospective cohort study includes all patients who underwent surgical treatment for TF in a single center from 2014 to 2018. Patient-, fracture-, and treatment characteristics were compared between the 3DRX and RX subgroups. The primary endpoint was the number of patients requiring revision surgery. Secondary endpoints were surgery duration, hospital length of stay, radiation exposure, postoperative complications, and secondary total knee arthroplasty. RESULTS: Eighty-seven patients were included, of which 36 were treated with 3DRX. Three patients in the RX group required revision surgery, while no revision surgery was performed in the 3DRX group (p = 0.265). The use of 3DRX resulted in significantly more intraoperative adjustments (25% versus 6%; p = 0.024) and an increase in surgery duration (by average of 28 min, p = 0.001), without a significant increase in postoperative wound infections (12% versus 19%; p = 0.374) or fracture-related infections (2% versus 2.8%; p = 0.802). The 3DRX group had an average radiation exposure of 7,985 mGy versus 1,273 mGy in the RX group (p<0.001). The hospital length of stay was 1 day shorter in the 3DRX group (5 days versus 4 days; p = 0.058). CONCLUSIONS: Implementing 3DRX in treating TFs improves the assessment of fracture alignment and implant position perioperatively, resulting in more intraoperative corrections and no revision surgeries within 6 weeks postoperatively. However, using 3DRX significantly increases perioperative radiation exposure and surgery duration without a significant rise in postoperative infections and a shorter hospital length of stay.

The value of digital 3D models in evaluating surgical outcomes using the uninjured contralateral acetabulum after acetabular fracture repair.

BACKGROUND: Currently, assessment of acetabular fracture reduction is mainly performed by evaluating 2D slices of 3D CT scans. This subjective method can potentially be improved by using 3D models and objective analysis tools. In order to evaluate the potential value of digital 3D reconstructed models in the assessment of acetabular fracture reduction, 3D reconstructions of the fractured acetabulum were compared to the mirrored healthy contralateral side for both the pre-, and post-surgical setting. METHODS: Thirteen patients with one-sided acetabular fractures were included in the study. All patients received a pre-, and postoperative CT scan. The similarity between the healthy acetabulum and the contralateral fractured acetabulum was determined by two observers for both the pre-, and postoperative setting by completing the following four steps; (1) mirroring of the fractured acetabulum, (2) initial manual alignment of this mirrored 3D model to the contralateral version, (3) surface-based matching (iterative closest point registration) using the acetabular cartilage surface, and (4) calculating the surface distances between affected and healthy acetabular 3D models. Descriptive statistics showed the surface distance between pre-, and post-surgical reduction, as well as the interobserver variability. RESULTS: A total of 13 patients with an acetabular fracture were included; 11 males and 2 females with a mean ± SD age of 55.6 ± 14.7 years. Digital mirroring of the fractured acetabula to the healthy acetabula was successful for both preoperative and postoperative situations in all patients. The median distance between both fractured and mirrored healthy contralateral acetabula was significantly larger (p<0.01) for the preoperative group (2.21 mm (interquartile range (IQR): 1.30 mm)) compared to the postoperative group (0.93 mm (IQR: 0.59 mm)). The median distance deviation was not significantly different (p = 0.96) between observers. CONCLUSIONS: The results of comparing 3D model of fractured acetabula with the contra-lateral healthy acetabula before, and after surgical repair indicate that this method can be a suitable tool to objectively assess acetabular fracture reduction. Further research is needed to confirm the usefulness to predict future arthrosis after surgical repair.

Comparison of segmentation software packages for in-hospital 3D print workflow.

Purpose: In-hospital three-dimensional (3D) printing of patient-specific pathologies is increasingly being used in daily care. However, the efficiency of the current conversion from image to print is often obstructed due to limitations associated with segmentation software. Therefore, there is a need for comparison of several clinically available tools. A comparative study has been conducted to compare segmentation performance of Philips IntelliSpace Portal® (PISP), Mimics Innovation Suite (MIS), and DICOM to PRINT® (D2P). Approach: These tools were compared with respect to segmentation time and 3D mesh quality. The dataset consisted of three computed tomography (CT)-scans of acetabular fractures (ACs), three CT-scans of tibia plateau fractures (TPs), and three CTA-scans of abdominal aortic aneurysms (AAAs). Independent-samples t -tests were performed to compare the measured segmentation times. Furthermore, 3D mesh quality was assessed and compared according to representativeness and usability for the surgeon. Results: Statistically significant differences in segmentation time were found between PISP and MIS with respect to the segmentation of ACs ( p = < 0.001 ) and AAAs ( p = 0.031 ). Furthermore, statistically significant differences in segmentation time were found between PISP and D2P for segmentations of AAAs ( p = 0.008 ). There were no statistically significant differences in segmentation time for TPs. The accumulated mesh quality scores were highest for segmentations performed in MIS, followed by D2P. Conclusion: Based on segmentation time and mesh quality, MIS and D2P are capable of enhancing the in-hospital 3D print workflow. However, they should be integrated with the picture archiving and communication system to truly improve the workflow. In addition, these software packages are not open source and additional costs must be incurred.

The value of 3D reconstructions in determining post-operative reduction in acetabular fractures: a pilot study.

BACKGROUND: In patients with acetabular fractures, the reconstructed three-dimensional (3D) model of the contralateral acetabulum could be used as a mirrored template for the anatomical configuration of the affected joint. This has not been validated. OBJECTIVE: To investigate whether the right and left acetabula, as reconstructed 3D models, are valid mirrored duplicates that can be used as a reference model for the contralateral side. METHODS: CT scans of twenty patients with unaffected acetabula were used. The symmetry of the generated 3D models was evaluated through: (1) mirroring of the acetabulum; (2) initial rough matching; (3) automatic optimisation of the matching via surface-based matching; (4) calculation of distances between surfaces by evaluating the Euclidean (straight-line) error distance between the closest points between left and right. The percentages of surface points of the left and right acetabulum with a distance smaller than 0.5, 1.0, 1.5 and 2.0 mm were calculated and evaluated, in relation to Matta's criteria, for acetabular fracture reductions. RESULTS: The mean distance deviation was less than 0.75 mm in all 40 comparisons. The calculated distances in 90.7% of the surface points of the left and right acetabulum were below the tolerance threshold of 1.0 mm, based on Matta's anatomical reduction criteria, and 98.7% of the surface points scored below Matta's imperfect tolerance threshold of 2.0 mm. CONCLUSION: This study demonstrates 3D reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. The next step will be to investigate these results in patients with reduced acetabular fractures.

What is the value of 3D virtual reality in understanding acetabular fractures?

BACKGROUND: Acetabular fractures are difficult to classify owing to the complex three-dimensional (3D) anatomy of the pelvis. 3D printing helps to understand and reliably classify acetabular fracture types. 3D-virtual reality (VR) may have comparable benefits. Our hypothesis is that 3D-VR is equivalent to 3D printing in understanding acetabular fracture patterns. METHODS: A total of 27 observers of various experience levels from several hospitals were requested to classify twenty 3D printed and VR models according to the Judet-Letournel classification. Additionally, surgeons were asked to state their preferred surgical approach and patient positioning. Time to classify each fracture type was recorded. The cases were randomized to rule out a learning curve. Inter-observer agreement was analyzed using Fleiss' kappa statistics (κ). RESULTS: Inter-observer agreements varied by observer group and type of model used to classify the fracture: medical students: 3D print (κ = 0.61), VR (κ = 0.41); junior surgical residents: 3D print (0.51) VR (0.54); senior surgical residents: 3D print (0.66) VR (0.52); junior surgeons: 3D print (0.56), VR (0.43); senior surgeons: 3D print (κ = 0.59), VR (κ = 0.42). Using 3D printed models, there was more agreement on the surgical approach (junior surgeons κ = 0.23, senior surgeons κ = 0.31) when compared with VR (junior surgeons κ = 0.17, senior surgeons 0.25). No difference was found in time used to classify these fractures between 3D printing and VR for all groups (P = 1.000). CONCLUSIONS: The Judet-Letournel acetabular classification stays difficult to interpret; only moderate kappa agreements were found. We found 3D-VR inferior to 3D printing in classifying acetabular fractures. Furthermore, the current 3D-VR technology is still not practical for intra-operative use.

Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol.

INTRODUCTION: A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS: In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION: The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER: NTR6833.

Trauma care before and after optimisation in a level I trauma Centre: Life-saving changes.

BACKGROUND: The implementation of trauma systems has led to a significant reduction in mortality and length of hospital stay. In our level I trauma centre, 24/7 in-hospital coverage was implemented, and a renovation of the trauma room took place to improve the trauma care. The aim of the present study was to examine the effect of the optimised in-hospital infrastructure in terms of mortality, processes and clinical outcomes. METHODS: We performed a retrospective cohort study of prospectively collected data. All adult trauma patients admitted to our trauma centre directly during two time periods (2010-2012 and 2014-2016) were included. Any patients below the age of 18 years and patients who underwent primary trauma screening in another hospital were excluded. Logistic and linear regression were used and adjusted for demographics and characteristics of trauma. The primary endpoint was mortality. The secondary endpoints were subgroups of earlier mortality rates and severely injured patients, processes and clinical outcomes. RESULTS: In period I, 1290 patients were included, and in period II, 2421. The adjusted mortality in the trauma room (odds ratio (OR): 0.18; CI: 0.05-0.63) and the total in-hospital mortality (OR: 0.63 CI: 0.42-0.95) showed a significant reduction in period II. The trauma room (TR) time decreased by 30 min (p < 0.001), and the time until CT decreased by 22 min (p < 0.001). The number of delayed diagnoses and complications were significantly lower in the second period, with an OR of 0.2 (CI: 0.1-0.2) and 0.4 (CI: 0.3-0.6), respectively. The hospital length of stay and ICU length of stay decreased significantly, -1.5 day (p = 0.010) and -1.8 days (p = 0.022) respectively. CONCLUSIONS: Optimisation of the in-hospital infrastructure related to trauma care resulted in improved survival rates in both severely injured patients as well as in the whole trauma population. Moreover, the processes and clinical outcomes improved, showing a shorter hospital length of stay, shorter TR time, fewer complications and fewer delayed diagnoses.

Validation study of 3D-printed anatomical models using 2 PLA printers for preoperative planning in trauma surgery, a human cadaver study.

INTRODUCTION: 3D printing contributes to a better understanding of the surgical approach, reduction and fixation of complex fractures. It is unclear how a 3D-printed model relates to a human bone. The accuracy of 3D-printed models is important to pre-bend plates and fit of surgical guides. We conduct a validation study in which we compare human cadavers with 3D-printed models to test the accuracy of 3D printing. METHODS: Nine specimens were scanned, volume rendered into 3D reconstructions and saved as STL data. All models were in a ratio of 1:1 printed on the Ultimaker 3 and Makerbot Replicator Z18. Two independent observers measured all distances between the K-wires on the human cadavers, 2DCT, 3D reconstruction, Meshlab and both printers. A paired Samples T test was used to compare the measurements between the different modalities. RESULTS: The least decrease in average distance in millimetres was seen in "the 3D printed pelvis 1", - 0.3 and - 0.8% on respectively the Ultimaker and Makerbot when compared with cadaver Pelvis (1) The 3D model of "Hand 2" showed the most decrease, - 2.5 and - 3.2% on the Ultimaker and Makerbot when compared with cadaver hand (2) Most significant differences in measurements were found in the conversion from 3D file into a 3D print and between the cadaver and 3D-printed model from the Makerbot. CONCLUSION: Our 3D printing process results in accurate models suitable for preoperative workup. The Ultimaker 3 is slightly more accurate than the Makerbot Replicator Z18. We advise that medical professionals should perform a study that tests the accuracy of their 3D printing process before using the 3D-printed models in medical practice.

3D printing for corrective osteotomy of malunited distal radius fractures: a low-cost workflow.

After a severe trauma, a 16-year-old female patient sustained multiple injuries, including a distal radius fracture of the left arm. This distal radius fracture eventually developed into a malunion. In this case, we demonstrate our preoperative low-cost workup for three-dimensional (3D) planned and assisted corrective osteotomy of a malunited distal radius fracture using an in-hospital 3D printer.

Is There a Threat Towards Medical Institutions, and What to Do?

Unfortunately the reality of today is that a terrorist threat in Europe has become evident. With increasing frequency we are confronted with attacks all across Europe, at least this is the perception. So is there a Threat? If look at the paper of Wolf et al (1), this describes an increase of terrorist attacks from 1999- 2006, the amount of victims due to these attacks increased exponentially. This means the attacks are getting more effective. The perpetrators are getting better and are learning how to injure or kill more victims. The techniques are getting more sophisticated. For example if we look at the Bali Bombing in 2002, here a second hit technique is used. The terrorist placed first a small bomb in a tourist area, knowing that this eventually will attract many people who rush in to help the victims. Then a second hit was done with a much larger bomb killing and wounding even a larger group of people. This is the goal of the terrorist, introducing terror, shocking the world, introduce fear. If we look at the attack in Nice, South France. They used a truck driving through a large tourist crowd, knowing that there would be many children and young people. This is their ultimate goal, shock the world. With that mindset, just imagine how shocking would it be to primary attack a medical institution. Our weakness as medical people is that we want to help people, In fact we gave a Hippocratic oath that we will always help other people, that is our job. We find it hard to believe that medical relief institutions will be attacked. If we look at the London bombing in 2005, one of the terrorists detonated the bomb in a bus. By coincidence this happened right in front of the British Medical Association with many doctors in the building at that time. All of them immediately went to the exploded bus to provide medical relieve, did they even think for a second that there maybe would be a second hit? We are to nice, and the terrorists know this. Historyhas proven to us that medical institutions are a potential goal. 2008 a terror attack in Mumbai, eight series of attacks were done between 26-29th of November. Eventually the terrorist where heading for the CAMA hospital. However because the hospital was alerted and were able to perform a complete lock down they were able to prevent additional casualties in the hospital itself. Are these rare incidents?

Necrotising fasciitis: a ticking time bomb?

Necrotising fasciitis (NF) is a destructive bacterial infection and has often been described in media reports as a 'flesh-eating disease', which if diagnosed late is associated with worse outcome. Unfortunately, diagnosing NF is difficult due to the similar presentation of NF compared with other types of skin and soft tissue infections. The early presentation of NF only shows tenderness, swelling, erythema and warm skin. Moreover, NF is normally accompanied with aberrant laboratory findings, mainly elevated C reactive protein (CRP) levels. In this case report we evaluate the diagnostic process of a patient with NF without aberrant infection parameters; both normal levels of CRP and white blood cell count were seen.

Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures.

BACKGROUND: Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking. METHODS: All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations. RESULTS: Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6-54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18-68 min) for tibial fractures and 55 min (range 47-150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity. CONCLUSION: The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.

Treatment of impacted greenstick forearm fractures in children using bandage or cast therapy: a prospective randomized trial.

BACKGROUND: To evaluate the relative risks and advantages of using soft bandage therapy (BT) for impacted greenstick fractures of the distal forearm compared with cast therapy (CT). METHODS: At a single center from September 2005 to October 2006 all patients with an impacted greenstick fracture were randomized to BT or CT. RESULTS: A total of 92 patients were randomized and assigned. No fracture displacement was seen. Three patients from the BT group were converted to standard treatment. A significant difference in pain was seen between both groups after 1 week in favor of the CT group. Discomfort was significantly less in the BT group compared with the CT group. After 4 weeks, the wrist function was significantly better in the BT group. After 6 weeks, the wrist functions of both the groups were comparable. CONCLUSIONS: BT for impacted greenstick fractures of the distal forearm is a safe technique, patients treated with bandage suffer greater pain at the start of the treatment, are able to return to normal activities sooner, and have less discomfort when compared with the standard CT.