A Review on the Use of Artificial Intelligence in Fracture Detection.

Artificial intelligence (AI) simulates intelligent behavior using computers with minimum human intervention. Recent advances in AI, especially deep learning, have made significant progress in perceptual operations, enabling computers to convey and comprehend complicated input more accurately. Worldwide, fractures affect people of all ages and in all regions of the planet. One of the most prevalent causes of inaccurate diagnosis and medical lawsuits is overlooked fractures on radiographs taken in the emergency room, which can range from 2% to 9%. The workforce will soon be under a great deal of strain due to the growing demand for fracture detection on multiple imaging modalities. A dearth of radiologists worsens this rise in demand as a result of a delay in hiring and a significant percentage of radiologists close to retirement. Additionally, the process of interpreting diagnostic images can sometimes be challenging and tedious. Integrating orthopedic radio-diagnosis with AI presents a promising solution to these problems. There has recently been a noticeable rise in the application of deep learning techniques, namely convolutional neural networks (CNNs), in medical imaging. In the field of orthopedic trauma, CNNs are being documented to operate at the proficiency of expert orthopedic surgeons and radiologists in the identification and categorization of fractures. CNNs can analyze vast amounts of data at a rate that surpasses that of human observations. In this review, we discuss the use of deep learning methods in fracture detection and classification, the integration of AI with various imaging modalities, and the benefits and disadvantages of integrating AI with radio-diagnostics.

Role of Negative Suction Therapy and Platelet-Rich Plasma in the Management of Delayed Post-operative Wound Healing: A Case Report.

Tibial Pilon fractures are rare yet devastating injuries. To classify these fractures, the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification system is the most commonly used method. Out of all the different types, type C fractures are the most difficult to manage because the enormous energy involved in creating this type of injury typically severely destroys the soft tissue surrounding the fracture zone. As a result, long-term outcomes are frequently poor, and proper initial primary care is critical. Pilon fractures are injuries that are difficult to manage, considering the poor soft tissue envelope. These injuries often are associated with delayed wound healing and require staged management. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. We share our experience in the management of AO type 43C3 grade I compound distal tibia fibular fracture with post-operative wound dehiscence, successfully managed with vacuum-assisted closure (VAC) and platelet-rich plasma (PRP) therapy.

Development of a diagnostic support system for distal humerus fracture using artificial intelligence.

PURPOSE: AI has shown promise in automating and improving various tasks, including medical image analysis. Distal humerus fractures are a critical clinical concern that requires early diagnosis and treatment to avoid complications. The standard diagnostic method involves X-ray imaging, but subtle fractures can be missed, leading to delayed or incorrect diagnoses. Deep learning, a subset of artificial intelligence, has demonstrated the ability to automate medical image analysis tasks, potentially improving fracture identification accuracy and reducing the need for additional and cost-intensive imaging modalities (Schwarz et al. 2023). This study aims to develop a deep learning-based diagnostic support system for distal humerus fractures using conventional X-ray images. The primary objective of this study is to determine whether deep learning can provide reliable image-based fracture detection recommendations for distal humerus fractures. METHODS: Between March 2017 and March 2022, our tertiary hospital's PACS data were evaluated for conventional radiography images of the anteroposterior (AP) and lateral elbow for suspected traumatic distal humerus fractures. The data set consisted of 4931 images of patients seven years and older, after excluding paediatric images below seven years due to the absence of ossification centres. Two senior orthopaedic surgeons with 12 + years of experience reviewed and labelled the images as fractured or normal. The data set was split into training sets (79.88%) and validation tests (20.1%). Image pre-processing was performed by cropping the images to 224 × 224 pixels around the capitellum, and the deep learning algorithm architecture used was ResNet18. RESULTS: The deep learning model demonstrated an accuracy of 69.14% in the validation test set, with a specificity of 95.89% and a positive predictive value (PPV) of 99.47%. However, the sensitivity was 61.49%, indicating that the model had a relatively high false negative rate. ROC analysis showed an AUC of 0.787 when deep learning AI was the reference and an AUC of 0.580 when the most senior orthopaedic surgeon was the reference. The performance of the model was compared with that of other orthopaedic surgeons of varying experience levels, showing varying levels of diagnostic precision. CONCLUSION: The developed deep learning-based diagnostic support system shows potential for accurately diagnosing distal humerus fractures using AP and lateral elbow radiographs. The model's specificity and PPV indicate its ability to mark out occult lesions and has a high false positive rate. Further research and validation are necessary to improve the sensitivity and diagnostic accuracy of the model for practical clinical implementation.

Utilizing an antibiotic-eluting articulated cemented spacer in the two-stage management of infected total hip arthroplasty: a technical note.

Two-stage revision is generally preferred to eradicate chronic periprosthetic infections after total hip arthroplasty (THA) because of its good infection control and promising results. During two-stage revision, a temporary antibiotic-impregnated cement spacer was initially used for the local delivery of antibiotics, thereby reducing the risk of infection recurrence. Many researchers have reported various techniques for fabricating cemented spacers; however, there is no established standard technique. We share our cost-effective and easily reproducible technique for creating an articulated cemented spacer for managing infected THA.

Multiligament knee injury with common peroneal nerve palsy in a long jump athlete with 4-year follow-up: A case report.

Introduction: Multiligament knee injuries (MLKIs) are difficult to manage occurrence and are usually associated with poor functional outcomes. Knee dislocations involving both cruciate ligaments are relatively rare compared to other multifilament injuries involving one cruciate ligament and a collateral ligament. Multiple studies have reported the Tegnor score after surgery as 3 or 4. In 44% of cases with posterolateral corner (PLC) injury and biceps femoris tendon rupture or avulsion of the fibular head, a palsy of the common peroneal nerve (CPN) occurs. About half of these cases do not exhibit functional recovery. Case Report: A 20 years old long jump national athlete sustained varus and hyperextension injury leading to a multiligament knee injury (anterior cruciate ligament, posterior cruciate ligament, PLC, and medial collateral ligament) and CPN palsy. After a staged surgical procedure and structured rehabilitation protocol, the athlete was able to return to preinjury level in 18 months. At present, 4 years postoperatively, the patient can walk full weight-bearing with no instability. On the latest follow-up, the Lachman's test is negative, posterior drawer test negative, varus, and valgus stress test negative. Knee ranges of motion 0 to 140 degrees. The patient reported that Tegnor Score was 8. Conclusion: Surgical management of MKLI with CPN palsy can give reasonable functional outcome.

The Utility of Supracutaneous Plating in the Staged Management of Compound Distal Femur Fracture: A Case Report.

The aim of this report is to draw attention to the use of a vilipend technique 'supracutaneous plating' in the management of compound distal femur fractures. Treatment of compound fractures of the distal femur with bone defects and microbial infection remains a challenging task for orthopaedic trauma surgeons. In this case report, we share our experience with the use of the locking distal femoral plate as an external fixator for the staged management of a compound infected distal femur fracture in a 22-year-old male patient. Staged procedures with proper planning give excellent results for infected fractures. Supracutaneous plating can be a viable and patient-friendly alternative in the staged management of compound distal femur fractures instead of the conventional external fixators.

Tibia Nailing Using Modular Stand: A Technical Note.

Interlocking nailing is a well-established procedure for managing unstable tibial shaft fractures. Closed reduction and internal fixation of the tibial shaft fractures require ease of intraoperative positioning, maneuvering, and biplane imaging. We describe the use of an innovative modular tibia-nailing stand, which greatly enhances the ergonomics of the tibia nailing procedure.

Crescent Fracture of the Pelvis: A Case Report.

Crescent fractures are a rare type of pelvic injury. They result from a lateral compression force and are rotationally unstable. The following is a case of a young male who suffered a crescent fracture on the right side of the pelvis and was treated for the same. These fractures, being rare and complex, need to be managed in accordance with other injuries sustained by the patient and also need fixation for a better functional outcome.

3D CT scan-based study of glenoid morphology in Indian population: Clinical relevance in design of reverse total shoulder arthroplasty.

BACKGROUND: The knowledge of normal anatomy of glenoid in a population has relevance in terms of comparison with other regional and national population. Furthermore, it could enable clinicians to judge whether the available sizes of reverse total shoulder arthroplasty (RTSA) prosthesis could provide optimal fit for the glenoid in Indian patients. METHODS: We evaluated consecutive 200 3-dimensional chest CT scans of 50 male and 50 female patients which included both shoulder joints and done for non-orthopaedic diseases at a tertiary care institute. The glenoid height, width, and version were measured using commercially available computer program. RESULTS: Mean age of the patents was 38.6 ± 13.8 years (range, 19-59 years). The mean glenoid height was 33.9 ± 3.1 mm and maximum glenoid width was 24.2 ± 2.1 mm. Mean glenoid version in the study population was a retroversion of 3.47 ± 4.7°. The maximum glenoid width of 45% female and 15% male patients was less than 25 mm which is the diameter of smallest available glenoid baseplate among the commonly used RTSA systems. CONCLUSIONS: The normal glenoid size of a large cohort of Indian population studied was smaller than that reported in cohorts from western countries. The glenoid width of substantial proportion of patients, especially female patients, was less than the diameter of smallest available glenoid baseplate. Clinical studies are needed in future in Indian patients undergoing RTSA to evaluate the glenoid bone-baseplate mismatch and ascertain the necessity of development of smaller size glenoid baseplate for optimal prosthesis fit in Indian patients.

Clinical and Imaging Outcomes After Revision Open Rotator Cuff Repair: A Retrospective Review of a Midterm Follow-Up Study.

BACKGROUND: Revision open rotator cuff repair (ORCR) has been associated with unpredictable functional outcome with concerns of deltoid detachment. The aim of this study was to evaluate the clinical and imaging outcomes of revision ORCR. MATERIALS AND METHODS: The study retrospectively reviewed 30 consecutive patients (mean age 60.4 ± 7.2 years) who underwent revision ORCR after failed rotator cuff repair. Pain visual analog scale (VAS), Constant and American Shoulder Elbow Surgeon (ASES) score were assessed preoperatively and at mean 58-month follow-up (range 24-120 months). The acromio-humeral distance (AHD) was measured on pre- and postoperative radiograph. Tear size and fatty infiltration of rotator cuff were evaluated by preoperative magnetic resonance imaging (MRI) study. The retear rate, change of fatty infiltration and deltoid origin integrity were evaluated by postoperative MRI. RESULTS: There was significant improvement of pain VAS and functional outcome scores (all p < 0.001). AHD showed no significant change after surgery. On postoperative MRI, the retear rate was 43% (13/30). However, the size of the tendon defect was smaller than that of pre-revision tear (p = 0.006). The patients who had intact tendon had significantly better functional outcomes than those with retear. The intact group had significantly higher AHD both pre- and postoperatively than the retear group. There was no change of fatty infiltration after surgery. Four patients (13%, 4/30) showed thinning of deltoid origin on postoperative MRI, but showed no weakness on clinical examination. CONCLUSION: Revision ORCR resulted in improved outcomes in pain relief and shoulder function, with low rate of subclinical deltoid thinning.

Do autologous blood transfusion systems reduce allogeneic blood transfusion in total knee arthroplasty?

PURPOSE: To study whether autologus blood transfusion systems reduce the requirement of allogneic blood transfusion in patients undergoing total knee arthroplasty. METHODS: A comprehensive search of the published literature with PubMed, Scopus and Science direct database was performed. The following search terms were used: (total knee replacement) OR (total knee arthroplasty) OR (TKA) AND (blood transfusion) OR (autologous transfusion) OR (autologous transfusion system). Using search syntax, a total of 748 search results were obtained (79 from PubMed, 586 from Science direct and 83 from Scopus). Twenty-one randomized control trials were included for this meta-analysis. RESULTS: The allogenic transfusion rate in autologus blood transfusion (study) group was significantly lower than the control group (28.4 and 53.5 %, respectively) (p value 0.0001, Relative risk: 0.5). The median units of allogenic blood transfused in study control group and control group were 0.1 (0.1-3.0) and 1.3 (0.3-2.6), respectively. The median hospital stay in study group was 9 (6.7-15.6) days and control group was 8.7 (6.6-16.7) days. The median cost incurred for blood transfusion per patient in study and control groups was 175 (85.7-260) and 254.7 (235-300) euros, respectively. CONCLUSION: This meta-analysis demonstrates that the use of auto-transfusion systems is a cost-effective method to reduce the need for and quantity of allogenic transfusion in elective total knee arthroplasty. LEVEL OF EVIDENCE: Level I.

Rotator cuff surgery in patients older than 75 years with large and massive tears.

BACKGROUND: The purpose of this study was to evaluate whether rotator cuff repair improves subjective and functional outcomes in patients aged ≥75 years. METHODS: From May 2005 to March 2013, 121 elderly patients who underwent rotator cuff repair for large and massive rotator cuff tears were evaluated retrospectively. Patients with an American Society of Anesthesiologists physical status classification system grade ≥4 were excluded. The patients were evaluated using visual analog scales, subjective satisfaction surveys, American Shoulder and Elbow Surgeons scores, and Constant scores. The Katz index of activity of daily living (ADL) and functional independence measure motor score were used to evaluate ADLs. Postoperative magnetic resonance imaging (MRI) was performed to investigate the structural integrity of repaired cuffs. RESULTS: In total, 64 patients were enrolled in the study; 80% were satisfied with their results. Visual analog scale scores improved from 6.4 to 2.3, American Shoulder and Elbow Surgeons scores from 42 to 84, and Constant scores from 42 to 76. Katz ADL scores improved from 3.4 to 5.0. Functional independence measure motor score improved from 22 to 51. Of the 64 patients, 46 underwent MRI 1 year postoperatively. Follow-up MRI revealed retears in 26% of patients. All patients with retears had improved subjective outcomes and functional scores. No patients died or experienced complications requiring intensive care or extended hospitalization. CONCLUSIONS: Surgical treatment for large to massive rotator cuff tears in elderly patients with American Society of Anesthesiologists grade <4 provides good functional outcomes without morbidity, even in those with retears.

Isolated coronoid fracture: Assessment by magnetic resonance imaging for concomitant injuries.

BACKGROUND: Ligamentous injury associated with isolated coronoid fracture had been sparingly reported. Concealed or unclear fractures and ligamentous or articular cartilage lesions are promptly acknowledged by magnetic resonance imaging (MRI) but cannot be entirely pictured in regular radiological assessments. In isolated coronoid fracture, the fragment size is very small and due to the complex anatomy surrounding the coronoid radiographic imaging may not be sufficient. The purpose of this study was to evaluate the incidence of combined osteochondral and ligamentous injuries by magnetic resonance imaging (MRI) in 24 patients with an isolated coronoid fracture. MATERIALS AND METHODS: In a retrospective study conducted at tertiary hospital between 2009 and 2011, elbow radiographs (anteroposterior and lateral views), computed tomography scan images, and MRI in the sagittal, coronal, axial, oblique, and coronal oblique planes were collected and reviewed. Musculoskeletal radiologist with subspecialty training in musculoskeletal MR interpretation and a fellowship-trained shoulder and elbow surgeon evaluated the MRI. RESULTS: The incidence of associated injuries revealed torn lateral collateral ligament (LCL) in all 24 patients (100%) while 15 patients (62.5%) had common extensor muscle tears. Seven of 24 elbows (29.2%) showed medial collateral ligament (MCL) tear, and 13 of 16 patients (81.3%) with anteromedial facet fracture had MCL attached to the fragment. Five of 24 (20.8%) cases had contusions on the radial head. On the distal humeral side, 15 patients had bone contusions on the posterior inferior of the trochlear on sagittal view. The ligament affections of the LCL were confirmed intraoperatively and repaired. CONCLUSION: LCL injury was consistent in all isolated coronoid fracture. The forces resulting in the injury appear similar to varus distraction forces acting in the knee leading to distraction injuries of the lateral structures of the knee joint. As concurrent osteochondral injuries and ligamentous injuries are not rare, magnetic resonance analysis serves as an excellent tool for analysis of the ligamentous injuries preoperatively and aids in surgical planning.

Dorsal apex curve of the proximal ulna.

OBJECTIVE: To analyze the apexes and angulations along the curvature in the posterior border of the proximal ulna-termed the "dorsal apex curve" (DAC)-using the computer-aided design software. METHODS: Eight pairs of normal cadaveric ulnae were analyzed. The ulnar Cartesian coordinate system was standardized using a user-defined coordinate systems feature. DAC was defined by the best-fit curvature of serial apexes in the posterior border in axial cross-sections along the ulna, whereas the best-fit curvature was obtained using polynomials interpolation method. DAC apexes in three different planes were determined by calculating the second derivative value of curve function, and subsequently, DAC angulations were calculated. Statistical analysis was performed using analysis of variance with repeated measures with significance level set as 0.001. RESULTS: The average ulnar length was 246±15 mm (224-274 mm). The average ratios of dorsal apex, varus apex, and edge point were 23±3% (17-27%), 33±4% (27-43%), and 10±1% (8-13%), respectively, relative to the ulnar length. The average amount of varus, dorsal, hook, and torsion angulation were 167±4° (157-172°), 176±1° (175-178°), 90±0°, and 31±10° (15-49°), respectively. We found no significant differences between left and right ulnae or between male and female ulnae. CONCLUSION: Dorsal apexes and angulations are important landmarks for surgeons when applying plates and attempting total elbow replacement surgery. This curve provides valuable information to medical manufacturers for modeling both plates and ulna components of artificial elbow joints.

A new wide-angle arthroscopic system: a comparative study with a conventional 30° arthroscopic system.

PURPOSE: To compare users' hand movements in performing validated shoulder arthroscopic tasks between a 30° and a wide-angle arthroscopic system, using phantom models with an optical motion analysis system. METHODS: Twelve orthopaedic residents were enrolled and randomly allocated into two groups. In order to compensate for any learning effect, a Latin square counterbalancing technique was used. An optical motion analysis system was used with markers affixed to pre-designed sites; each participant conducted four validated shoulder arthroscopic tasks using both arthroscopic systems. Each participant was instructed to perform the experiment three times with each arthroscope. The time taken, total path length, number of movements, and average acceleration were analysed. RESULTS: Significant differences were observed for the time taken, number of movements, and average acceleration between the two arthroscopic systems (P < 0.05 for all). However, the time taken was not significant. The mean total path length measured 53 ± 38 cm with the 30° arthroscope, while the mean with the wide-angle arthroscope was significantly shorter, at 36 ± 22 cm. The mean number of movements with the 30° and wide-angle arthroscopes were 1974 ± 1305 and 1233 ± 990, respectively, while the average accelerations were 2.6 ± 1.3 and 1.2 ± 0.6 cm/s(2), respectively. The mean time taken was 13 % faster when using the wide-angle arthroscopic system, although this was not statistically significant. CONCLUSION: The wide-angle arthroscopic system improved the arthroscope manoeuvre in terms of the total path length, number of movements, and average acceleration required for experimental arthroscopy. This system may help surgeons triangulate the arthroscope and surgical instruments during surgery by expanding the field of view.

Comparative analysis of visual field and image distortion in 30° and 70° arthroscopes.

PURPOSE: There have been very few attempts to compare the visual fields and image distortion in arthroscopes. To better understand the images generated using existing arthroscopes, we performed image-mapping experiments to assess field of view and image distortion. The purpose of this study was to quantify and compare the visual fields obtained using 30° and 70° arthroscopes and assess image distortion in each arthroscope. METHODS: A complete arthroscopy system was used in this study. To perform this quantitative analysis, we created a customized measurement device that consisted of three parts: (1) distance marker, (2) chessboard pattern, and (3) angle marker. Three observers collectively assessed the appropriate position of the arthroscope during simulation. For each scope, ten simulations were performed at distances between 1 and 3 cm. Using the obtained arthroscope images, field of view and image distortion were measured and calculated. RESULTS: The field of view of the 70° arthroscope was 5, 10, and 15 mm wider in diameter in comparison with the 30° arthroscope at 1, 2, and 3 cm, respectively. Moreover, the 70° arthroscope had less 0.66, 0.13, and 0.26 pixels of root-mean-square distance than the 30° arthroscope at 1, 2, and 3 cm, respectively. The 70° arthroscope also contained 0.78 pixels less at the maximal error than the average 30° arthroscope. Therefore, the 70° arthroscope demonstrated less distortion than the 30° arthroscope. There was no significant difference between the two scopes with respect to median curvature measurement at 1-cm distance. CONCLUSION: The 70° arthroscope demonstrates technical advantages over the 30° arthroscope, including a wider field of view and a less image distortion at the periphery. A wide angle and less image distortion can help better orient the surgeon within the joint cavity when a panoramic picture is needed to repair rotator cuff tears, in case of hip arthroscopy, or while treating the lesions of posterior horn of medial meniscus.

Magnetic resonance appearance of bioabsorbable anchor screws for double row arthroscopic rotator cuff repairs.

BACKGROUND: Little is known about the bioabsorbable, anchor related postoperative changes in rotator cuff surgery, which has become more popular recently. The purpose of the present study was to use magnetic resonance imaging (MRI) to analyze the degradation of bioabsorbable anchors and to determine the incidences and characteristics of early postoperative reactions around the anchors and their mechanical failures. MATERIALS AND METHODS: Postoperative MRIs of 200 patients who underwent arthroscopic rotator cuff repair were retrospectively analyzed. The tissue reactions around the bioanchors included fluid accumulations around the anchor, granulation tissue formation and changes in the condition of the surrounding osseous structure. The condition of the bioanchor itself was also examined, including whether the bioanchor failed mechanically. In the case of mechanical failure, the location of the failure was noted. Serial MRIs of 18 patients were available for analysis. RESULTS: The total number of medial row bioanchors was 124, while that of the lateral row was 338. A low signal intensity rim suggestive of sclerosis surrounded all lateral row bioanchors. Ninety three lateral row bioanchors (27%) showed a rim with signal intensity similar to or less than that of surrounding bone, which was granulation tissue or foreign body reaction (FBR). Similar signal intensity was seen around nine medial row bioanchors (7%). Fluid accumulation was seen around 4 lateral row bioanchors (1%) and around 14 medial row bioanchors (11%). Five lateral row bioanchors showed the breakage, while there was none in the medial row bioanchors. There were nine cases with a cuff re-tear (4.5%). There was no evidence of affection of glenohumeral articular surfaces or of osteolysis around any bioanchor. In serial MRI, there was no change in appearance of the bioanchors, but the granulation tissue or FBR around four bioanchors and the fluid around one bioanchor showed a decrease in successive MRI. CONCLUSION: This study highlights the normal and adverse reactions to Bioabsorbable anchors that surgeons can expect to see on MRI after rotator cuff repairs.

Arthroscope assisted intralesional curettage of GCT.

INTRODUCTION: Incomplete intralesional curettage remains the most important factor contributing to the recurrence of the GCT tumor. A 360 degree view of the tumor cavity can be achieved with the help of an arthroscope, which can aid complete intralesional curettage. CASE REPORT: This technical note describes the use of arthroscope assisted curettage of the distal femur GCT. CONCLUSION: Use of an arthroscope can improve the visibility for intralesional curettage 5 of Giant Cell tumor.

Rapidly destructive arthrosis of the shoulder joints: radiographic, magnetic resonance imaging, and histopathologic findings.

BACKGROUND: Rapidly destructive arthrosis of the humeral head is a rare condition with an elusive pathophysiologic mechanism. In this study, radiographic and histopathologic findings were analyzed to determine the clinical characteristics of this rare condition. METHODS: We retrospectively analyzed 189 patients who underwent total shoulder arthroplasty from January 2001 to August 2012. Among them, 9 patients showed a particular pattern of rapid collapse of the humeral head on plain radiography and magnetic resonance imaging (MRI) within 12 months from symptom onset. Patients with trauma, rheumatoid arthritis, steroid intake, neurologic osteoarthropathy, osteonecrosis, renal osteoarthropathy, or gout were excluded. RESULTS: All patients were women, with a mean age of 72.0 years (range, 63-85 years). The right side was involved in 7 cases and the left in 2 cases. The mean duration of humeral head collapse was 5.6 months (range, 2-11 months) from the onset of shoulder pain. Plain radiographs of all patients showed a unique pattern of humeral head flattening, which appeared like a clean surgical cut with bone debris around the humeral head. MRI findings revealed significant joint effusion and bone marrow edema in the humeral head, without involvement of the glenoid. Pathologic findings showed both fragmentation and regeneration of bone matrix, representing fracture healing. CONCLUSION: The important features of rapidly destructive shoulder arthrosis are unique flattened humeral head collapse with MRI showing massive joint effusion and bone marrow edema in the remnant humeral head. This condition should be considered in the differential diagnosis of elderly women with insidious shoulder pain.