Spontaneous Closure of Congenital Cranial Defect: Is Early Surgical Intervention Warranted?

Infantile cranial development typically occurs in a predictable sequence of events; however, less is known about how the development occurs in isolated, nonsyndromic congenital craniofacial anomalies. Furthermore, the timing of pediatric cranioplasty has been extrapolated from adult studies. Thus, the management of nonsyndromic congenital craniofacial anomalies presents with unique challenges to the craniofacial surgeon. The authors describe the case of a baby girl who was born with right Tessier 3 cleft, cleft palate, anophthalmos, and severe left craniofacial microsomia with Pruzansky grade III left mandibular anomaly. By analyzing 3-dimensional chronological models of the patient, the authors found that her abnormal fontanelle initially increased in size until 22 weeks of age, with subsequent spontaneous closure at a rate of 60.53 mm2/y. Although similar cranial anomalies are typically surgically corrected early in life, delaying treatment until after 2 years of age may be appropriate in some patients, obviating surgical morbidity in the newborn period.

Artificial intelligence and spine imaging: limitations, regulatory issues and future direction.

BACKGROUND: As big data and artificial intelligence (AI) in spine care, and medicine as a whole, continue to be at the forefront of research, careful consideration to the quality and techniques utilized is necessary. Predictive modeling, data science, and deep analytics have taken center stage. Within that space, AI and machine learning (ML) approaches toward the use of spine imaging have gathered considerable attention in the past decade. Although several benefits of such applications exist, limitations are also present and need to be considered. PURPOSE: The following narrative review presents the current status of AI, in particular, ML, with special regard to imaging studies, in the field of spinal research. METHODS: A multi-database assessment of the literature was conducted up to September 1, 2021, that addressed AI as it related to imaging of the spine. Articles written in English were selected and critically assessed. RESULTS: Overall, the review discussed the limitations, data quality and applications of ML models in the context of spine imaging. In particular, we addressed the data quality and ML algorithms in spine imaging research by describing preliminary results from a widely accessible imaging algorithm that is currently available for spine specialists to reference for information on severity of spine disease and degeneration which ultimately may alter clinical decision-making. In addition, awareness of the current, under-recognized regulation surrounding the execution of ML for spine imaging was raised. CONCLUSIONS: Recommendations were provided for conducting high-quality, standardized AI applications for spine imaging.

Lumbar facet joint subchondral bone density in low back pain and asymptomatic subjects.

OBJECTIVE: To report in vivo measurements of lumbar facet joint subchondral bone mineral density used in the description of facet joint loading patterns and to interrogate if low back pain is associated with changes in subchondral bone mineral density. MATERIALS AND METHODS: In vivo measurements of lumbar facet joint subchondral bone mineral density (L1/2 to L5/S1) in Hounsfield units were performed on 89 volunteers (56 controls and 33 with low back pain) by computed tomography osteoabsorptiometry at subchondral regions between 1.5 mm and 2.5 mm below the joint surface. The facet surface was divided into five topographic zones: cranial, lateral, caudal, medial, and central. RESULTS: We analyzed 1780 facet joint surfaces. Facets were denser (p < 0.0001) both in superior facets and in low back pain subjects (p < 0.0001). For the entire cohort, the facet center zone subchondral bone mineral density was higher (p < 0.0001) than that of the peripheral zones. The analyses indicate that subchondral bone mineral density is highest in patients with low back pain, the superior facets, and the center zone of the facets. CONCLUSIONS: Subchondral bone mineral density is thought to reflect cumulative, long-term distribution of stress acting on a joint. This work shows that higher subchondral bone mineral density values in the center zone indicate predominant stress transmission through the center of the facet joints. Finally, the greater subchondral bone mineral density in patients with low back pain may reflect both increased load bearing by the facets secondary to disc degeneration and misdistribution of loading within the joint.

Computed Tomography-Based Three-Dimensional Analyses Show Similarities in Anterosuperior Acetabular Coverage Between Acetabular Dysplasia and Borderline Dysplasia.

PURPOSE: (1) To compare the acetabular coverage between dysplasia, borderline dysplasia, and control acetabulum in a quantitative 3-dimensional manner; and (2) to evaluate correlations between the radiologic parameters and the 3-dimensional zonal-acetabular coverage. METHODS: We reviewed contralateral hip computed tomography images of patients 16 to 60 years of age who underwent 1 of 3 types of surgeries: eccentric rotational acetabular osteotomy, curved intertrochanteric varus osteotomy, and total hip replacement with minimum 1-year follow-up from January 2013 to April 2018. A point-cloud model of the acetabulum created from computed tomography was divided into 6 zones. Three-dimensional acetabular coverage was measured radially at intervals of 1°. Mean radial acetabular coverage for each zone was named ZAC (zonal acetabular coverage) and was compared among the 3 subgroups (control: 25° ≤lateral center-edge angle [LCEA] <40°; borderline: 20° ≤LCEA <25°; and dysplasia: LCEA ≤20°) statistically. Further, the correlations between the ZAC in each zone and the LCEA were analyzed using Pearson's correlation coefficient. RESULTS: One-hundred fifteen hips were categorized as control (36 hips), borderline (32 hips), and dysplasia (47 hips). The mean anterocranial ZAC in the borderline (87.5 ± 5.7°) was smaller than that in the control (92.6 ± 5.9°, P = .005) but did not differ compared with the dysplasia (84.5 ± 7.6°, P = .131). In contrast, the anterocaudal (71.2 ± 5.0°), posterocranial (85.0 ± 6.4°), and posterocaudal (82.4 ± 4.5°) mean ZACs in the borderline were not different from those in the control (anterocaudal, 74.3 ± 4.6°, P = .090; posterocranial, 87.9 ± 4.3°, P = .082; posterocaudal, 85.1 ± 5.0°, P = .069) respectively. Although there was a very strong positive correlation with supra-anterior ZAC and LCEA (r = 0.750, P < .001), the correlation between the anterocranial ZAC and LCEA was relatively weak (r = 0.574, P < .001). CONCLUSIONS: The anterosuperior acetabular coverage in the borderline dysplastic acetabulum is more similar to the dysplastic acetabulum than to the normal acetabulum. CLINICAL RELEVANCE: This study emphasizes the importance of evaluating not only the lateral but also the anterior coverage in borderline dysplasia.

Spatial geometric and magnetic resonance signal intensity changes with advancing stages of nucleus pulposus degeneration.

BACKGROUND: With advancing stages of degeneration, denaturation and degradation of proteoglycans in the nucleus pulposus (NP) lead to tissue dehydration and signal intensity loss on T2-weighted MR images. Pfirrmann grading is widely used for grading degeneration of intervertebral discs (IVDs). The criterion to differentiate IVDs of Pfirrmann Grade I from the other grades is NP homogeneity. Pfirrmann grading is qualitative and its assessment may be subjective. Therefore, assessment of quantitative objective measures correlating with early disc degeneration may complement the grading. This study aimed to evaluate the applicability of the distance between the center weighted by signal intensity (weighted center) and the geometric center as a parameter of NP homogeneity. Other phenomena related to advancing stages of degeneration were also investigated. METHODS: MR images of 65 asymptomatic volunteers with a total of 288 lumbar IVDs with clearly identifiable nucleus pulposus boundary (Pfirrmann Grade I, II and III) were included in this study. A custom-written program was developed to determine the IVD longitudinal axis, define the NP boundary, and to locate the coordinates of geometric and weighted NP centers on the mid-sagittal image of each studied IVD. The distances between the weighted and geometric centers on the longitudinal axis and the perpendicular axis of each IVD were calculated. RESULTS: The weighted center located posterior to the geometric center, which indicated the signal intensity was lower at the anterior portion of the NP, in 85.8% of studied IVDs. The distance between the weighted and geometric center on the longitudinal axis was significantly shorter in homogeneous (Pfirrmann Grade I) than in inhomogeneous (Grade II) IVDs. The distance on the perpendicular axis in Grade III IVDs was significantly larger than that in Grade I and Grade II IVDs. CONCLUSION: The relationship between the weighted and geometric centers can serve as an indicator for NP homogeneity. The distance between both centers through advancing stages of degeneration demonstrated decrease of signal intensity progressing along the longitudinal axis initially and then along the cranio-caudal direction at later stages. These findings could provide insights of initiation and subsequent progression of degenerative changes in IVDs.

Capsulotomy Size Affects Hip Joint Kinematic Stability.

PURPOSE: To evaluate the effect of capsulotomy size and subsequent repair on the biomechanical stability of hip joint kinematics through external rotation of a cadaveric hip in neutral flexion. METHODS: Eight fresh-frozen cadaveric hip specimens were used in this study. Each hip was tested under torsional loads of 6 N·m applied by a servohydraulic frame and transmitted by a pulley system. The test conditions were (1) neutral flexion with the capsule intact, (2) neutral flexion with a 4-cm interportal capsulotomy, (3) neutral flexion with a 6-cm capsulotomy, and (4) neutral flexion with capsulotomy repair. Soft tissue was retained during all interventions. Measures indicating joint kinematics (range of motion [ROM], hysteresis area [HA], and neutral zone [NZ]) were obtained for each condition. RESULTS: For all hip specimens, the average ROM, HA, and NZ were calculated relative to the intact capsular state (100%) and expressed in terms of percentage (± SD). The findings for ROM were as follows: intact, 100%; 4 cm, 107.42% ± 5.69%; 6 cm, 113.40% ± 7.92%; and repair, 99.78% ± 3.77%. The findings for HA were as follows: intact, 100%; 4 cm, 108.30% ± 9.30%; 6 cm, 115.30% ± 13.92%; and repair, 99.47% ± 4.12%. The findings for NZ were as follows: intact, 100%; 4 cm, 139.61% ± 62.35%; 6 cm, 169.25% ± 78.19%; and repair, 132.03% ± 64.38%. Statistically significant differences in ROM existed between the intact and 4-cm conditions (P = .039), the intact and 6-cm conditions (P < .0001), the 4-cm and repair conditions (P = .033), and the 6-cm and repair conditions (P < .0001). There was no statistically significant difference between the intact and repair conditions (P > .99) or between the 4- and 6-cm conditions (P = .126). CONCLUSIONS: Under laboratory-based conditions, larger-sized capsulotomies were accompanied by increases in all 3 measures of joint mobility: ROM, HA, and NZ at time zero. Complete capsular closure effectively restored these measures when compared with the intact condition. CLINICAL RELEVANCE: Cadaveric models consisting of the hip joint with surrounding soft tissue were used under laboratory testing conditions to investigate potential iatrogenic joint instability resulting from expansive capsulotomies, showing that complete capsular closure leads to reconstitution of original joint stability properties at time zero.

Effects of Axial Torsion on Disc Height Distribution: An In Vivo Study.

OBJECTIVES: Axial rotation of the torso is commonly used during manipulation treatment of low back pain. Little is known about the effect of these positions on disc morphology. Rotation is a three-dimensional event that is inadequately represented with planar images in the clinic. True quantification of the intervertebral gap can be achieved with a disc height distribution. The objective of this study was to analyze disc height distribution patterns during torsion relevant to manipulation in vivo. METHODS: Eighty-one volunteers were computed tomography-scanned both in supine and in right 50° rotation positions. Virtual models of each intervertebral gap representing the disc were created with the inferior endplate of each "disc" set as the reference surface and separated into 5 anatomical zones: 4 peripheral and 1 central, corresponding to the footprint of the annulus fibrosus and nucleus pulposus, respectively. Whole-disc and individual anatomical zone disc height distributions were calculated in both positions and were compared against each other with analysis of variance, with significance set at P < .05. RESULTS: Mean neutral disc height was 7.32 mm (1.59 mm). With 50° rotation, a small but significant increase to 7.44 mm (1.52 mm) (P < .0002) was observed. The right side showed larger separation in most levels, except at L5/S1. The posterior and right zones increased in height upon axial rotation of the spine (P < .0001), whereas the left, anterior, and central decreased. CONCLUSIONS: This study quantified important tensile/compressive changes disc height during torsion. The implications of these mutually opposing changes on spinal manipulation are still unknown.

Biomechanical Evaluation of Capsulotomy, Capsulectomy, and Capsular Repair on Hip Rotation.

PURPOSE: To determine the effect of different types of capsulotomies on hip rotational biomechanical characteristics. METHODS: Seven fresh-frozen cadaveric hip specimens were thawed and dissected, leaving the hip capsule and labrum intact. The femur was transected and potted, and each specimen was placed in a custom loading apparatus that allowed for adjustment of flexion, extension, and axial rotation of the femur. Six reflective infrared markers were attached to the specimens to track the motion of the femoral head with respect to the acetabulum in real time, and external rotation was produced by applying a torque of 10 Nm to the hip specimens. Data analysis was performed using the 3-dimensional position of the markers in space. The specimens were tested in neutral flexion and 40° of flexion in the following capsular states: intact, interportal capsulotomy, T-capsulotomy, repaired capsulotomy, and capsulectomy. Paired t tests and analysis of variance were used with an α value of .05 set as significant. RESULTS: With the hip in neutral flexion, there was increased external rotation with a T-capsulotomy (91.1° ± 20.3°, P = .029) and capsulectomy (91.9° ± 19.6°, P = .015) compared with the intact hip (83.2° ± 20.5°). After complete repair of the T-capsulotomy (87.4° ± 20.6°), there was no significant difference in external rotation compared with the intact hip. No significant differences were seen between groups at 40° of hip flexion. CONCLUSIONS: A T-capsulotomy showed significantly increased external rotation versus the intact and interportal capsulotomy states. The repaired T-capsulotomy restored the rotational profile back to the native state. CLINICAL RELEVANCE: Many methods of capsular treatment during hip arthroscopy exist. Capsulotomy and capsulectomy do not restore the external rotation restraint of the hip back to its native state.

3.0T magnetic resonance imaging-based hip bone models for femoroacetabular impingement syndrome are equivalent to computed tomography-based models.

This study aimed to compare three-dimensional (3D) proximal femoral and acetabular surface models generated from 3.0T magnetic resonance imaging (MRI) to the clinical gold standard of computed tomography (CT). Ten intact fresh-frozen cadaveric hips underwent CT and 3.0T MRI scans. The CT- and MRI-based segmented models were superimposed using a validated 3D-3D registration volume-merge method to compare them. The least surface-to-surface distance between the models was calculated by a point-to-surface calculation algorithm using a custom-written program. The variables of interest were the signed and absolute surface-to-surface distance between the paired bone models. One-sample t-tests were performed using a signed and absolute test value of 0.16 mm and 0.37 mm, respectively, based on a previous study that validated 1.5T MRI bone models by comparison with CT bone models. For the femur, the average signed and absolute surface-to-surface distance was 0.18 ± 0.09 mm and 0.30 ± 0.06 mm, respectively. There was no difference in the signed surface-to-surface distance and the 0.16 mm test value (t = 0.650, p = 0.532). However, the absolute surface-to-surface difference was less than the 0.37 mm test value (t = -4.025, p = 0.003). For the acetabulum, the average signed and absolute surface-to-surface distance was -0.06 ± 0.06 mm and 0.26 ± 0.04 mm, respectively. The signed (t = -12.569, p < 0.001) and absolute (t = -8.688, p < 0.001) surface-to-surface difference were less than the 0.16 mm and 0.37 mm test values, respectively. Our data shows that 3.0T MRI bone models are more similar to CT bone models than previously validated 1.5T MRI bone models. This is likely due to the higher resolution of the 3T data.

Ulnar Bowing and Distal Radioulnar Joint Anatomy: A Three-Dimensional, In Situ Clinical Assessment.

Purpose: Distal radioulnar joint (DRUJ) injuries can be devastating and challenging to manage. The multiplanar curvature exhibited by the ulna impacts the morphology of the DRUJ, making it difficult to assess through two-dimensional radiographs alone. We used full-length, three-dimensional (3D) computed tomography angiography scans to assess the relationship between ulnar bowing, DRUJ ulnar variance (UV), and sigmoid notch angle. The goal of this study was to establish normal anatomic ranges for these landmarks to improve treatment for forearm traumas and DRUJ pathologies. Methods: Eighty-two intact upper extremity computed tomography angiography scans were examined and reconstructed into 3D models. We characterized ulnar bowing and DRUJ metrics using computer-aided design software. Measures of central tendency and Pearson correlation coefficients were calculated for comparative analysis. Results: The study yielded an average ulnar length of 272.3 mm. We identified the proximal ulnar bow at 36.7% of the bone's total length, possessing a depth of 10.3 mm, a proximal angle of 6.6°, and a distal angle of 3.9°. The distal ulnar bow appeared at 75.3% of the bone's length, characterized by a depth of 4.2 mm, a proximal angle of 2°, and a distal angle of 4.3°. In the coronal plane, the proximal angle of the proximal ulnar bow correlated positively with UV (r = 0.39, P < .001), whereas the distal angle of the distal ulnar bow correlated negatively (r = -0.48, P < .001). We also found significant correlations between the depths of both proximal and distal bows with UV (r = 0.38, P < .001; r = -0.34, P < .001, respectively). Moreover, UV within the DRUJ strongly correlated with the sigmoid notch angle (r = -0.77, P = .01). In contrast, the sagittal plane metrics did not show meaningful correlations with UV. Conclusion: Sagittal alignment and translation at the DRUJ articulation are directly related to ulna bowing at the distal ulna. A nuanced understanding of these 3D relationships can enhance preoperative planning when correcting ulnar-side pathology. Type of study/level of evidence: Therapeutic IV.

Patient-Specific Distal Femoral Guides Optimize Cartilage Topography Matching in Osteochondral Allograft Transplantations.

BACKGROUND: Osteochondral allograft (OCA) transplantation is an important surgical technique for full-thickness chondral defects in the knee. For patients undergoing this procedure, topography matching between the donor and recipient sites is essential to limit premature wear of the OCA. Currently, there is no standardized process of donor and recipient graft matching. PURPOSE: To evaluate a novel topography matching technique for distal femoral condyle OCA transplantation using 3-dimensional (3D) laser scanning to create 3D-printed patient-specific instrumentation in a human cadaveric model. STUDY DESIGN: Descriptive laboratory study. METHODS: Human cadaveric distal femoral condyles (n = 12) underwent 3D laser scanning. An 18-mm circular osteochondral recipient defect was virtually created on the medial femoral condyle (MFC), and the position and orientation of the best topography-matched osteochondral graft from a paired donor lateral femoral condyle (LFC) were determined using an in silico analysis algorithm minimizing articular step-off distances between the edges of the graft and recipient defect. Distances between the entire surface of the OCA graft and the underneath surface of the MFC were evaluated as surface mismatch. Donor (LFC) and recipient (MFC) 3D-printed patient-specific guides were created based on 3D reconstructions of the scanned condyles. Through use of the guides, OCAs were harvested from the LFC and transplanted to the reamed recipient defect site (MFC). The post-OCA recipient condyles were laser scanned. The 360° articular step-off and cartilage topography mismatch were measured. RESULTS: The mean cartilage step-off and graft surface mismatch for the in silico OCA transplant were 0.073 ± 0.029 mm (range, 0.005-0.113 mm) and 0.166 ± 0.039 mm (range, 0.120-0.243 mm), respectively. Comparatively, the cadaveric specimens postimplant had significantly larger step-off differences (0.173 ± 0.085 mm; range, 0.082-0.399 mm; P = .001) but equivalent graft surface topography matching (0.181 ± 0.080 mm; range, 0.087-0.396 mm; P = .678). All 12 OCA transplants had mean circumferential step-off differences less than a clinically significant cutoff of 0.5 mm. CONCLUSION: These findings suggest that the use of 3D-printed patient-specific guides for OCA transplantation has the ability to reliably optimize cartilage topography matching for LFC to MFC transplantation. This study demonstrated substantially lower step-off values compared with previous orthopaedic literature when also evaluating LFC to MFC transplantation. Using this novel technique in a model performing MFC to MFC transplantation has the potential to yield further enhanced results due to improved radii of curvature matching. CLINICAL RELEVANCE: Topography-matched graft implantation for focal chondral defects of the knee in patients improves surface matching and has the potential to improve long-term outcomes. Efficient selection of the allograft also allows improved availability of the limited allograft sources.

Gut microbiome dysbiosis is associated with lumbar degenerative spondylolisthesis in symptomatic patients.

Background: Lumbar degenerative spondylolisthesis (LDS), characterized as degeneration of the intervertebral disc and structural changes of the facet joints, is a condition with varying degrees of instability that may lead to pain, canal stenosis, and subsequent surgical intervention. However, the etiology of LDS remains inconclusive. Gut microbiome dysbiosis may stimulate systemic inflammation in various disorders. However, the role of such dysbiosis upon spine health remains under-studied. The current study assessed the association of gut microbiome dysbiosis in symptomatic patients with or without LDS. Methods: A cross-sectional analysis within the framework of a prospective study was performed. DNA was extracted from fecal samples collected from adult symptomatic patients with (n = 21) and without LDS (n = 12). Alpha and beta diversity assessed differences in fecal microbial community between groups. Taxon-by-taxon analysis identified microbial features with differential relative abundance between groups. Subject demographics and imaging parameters were also assessed. Results: There was no significant group differences in age, sex, race, body mass index, smoking/alcohol history, pain profiles, spinopelvic alignment, and Modic changes (p >0.05). LDS subjects had significantly higher disc degeneration severity (p = 0.018) and alpha diversity levels compared to non-LDS subjects (p = 0.002-0.003). Significant differences in gut microbial community structure were observed between groups (p = 0.046). Subjects with LDS exhibited distinct differences at the phylum level, with a significantly higher Firmicutes to Bacteroidota ratio compared to non-LDS (p = 0.003). Differential relative abundance analysis identified six taxa with significant differences between the two groups, with LDS demonstrating an increase in putative pro-inflammatory bacteria (Dialister, CAG-352) and a decrease in anti-inflammatory bacteria (Slackia, Escherichia-Shigella). Conclusion: This study is the first to report a significant association of gut microbiome dysbiosis and LDS in symptomatic patients, noting pro-inflammatory bacterial taxa. This work provides a foundation for future studies addressing the role of the gut microbiome in association with spine health and disease.

Emerging ideas: Novel 3-D quantification and classification of cam lesions in patients with femoroacetabular impingement.

BACKGROUND: Femoroacetabular impingement (FAI) can lead to labral injury, osseous changes, and even osteoarthritis. The literature contains inconsistent definitions of the alpha angle and other nonthree-dimensional (3-D) radiographic measures. We present a novel approach to quantifying cam lesions in 3-D terms. Our method also can be used to develop a classification system that describes the exact location and size of cam lesions. QUESTIONS/HYPOTHESES: We asked whether automated quantification of CAM lesions based on CT data is a reasonable way to detect CAM lesions and whether they may be classified based on location. METHOD OF STUDY: We developed a method to quantify femoral head cam lesions using 3-D modeling of CT scans. By segmenting raw DICOM data, we can determine the distance from the cam lesion's surface points to the centroid of the femoral head to quantify the mean bump height, volume, and location. The resulting 3-D femoral and acetabular models will be analyzed with custom software. We then will quantify the cam lesion with 3-D parameters using a modified zoning method. The mean bump height, volume, and location on the clock face, and relative zoning will be calculated. Zonal differences will be statistically analyzed. To assess the ability of this method to predict arthroscopic findings, we will obtain preoperative CT scans for 25 patients who undergo hip arthroscopy for FAI. We will compare measurements with the method with our measurements from arthroscopy. The clinical implications of our method's measurements then will be reviewed and refined for future prospective studies. SIGNIFICANCE: We present a novel approach that can quantify a cam lesion's location and size. This method will be used to provide guidelines for the exact amount of bony resection needed from a specific location of the proximal femur. There is also potential to develop software for ease of use so this method can be more widely applied.

Computed tomographic analysis of curved and straight guides for placement of suture anchors for acetabular labral refixation.

PURPOSE: The purpose of this study was to compare suture anchor placement in the acetabular rim between straight and curved drill guides regarding angle and distance of the suture anchor tip from the articular cartilage during labral refixation. METHODS: A total of 14 fresh-frozen cadaveric hips underwent arthroscopic labral incision from the 12 to 3 o'clock positions and subsequent repair with either a curved drill guide or a straight drill guide. These hips were then compared by computed tomographic imaging analysis by measuring the angle of suture anchor insertion and the distance of the tip of the suture anchor to the articular cartilage at the 1 o'clock, 2 o'clock, and 3 o'clock positions. RESULTS: The curved suture anchor (CSA) guide significantly increased the insertion angle (P = .009) and distance from the articular cartilage to anchor (P = .003) at the 1 o'clock position on the acetabulum. The angle of insertion at the 2 and 3 o'clock positions was greater for the CSA guide compared with the straight suture anchor (SSA) guide but did not reach statistical significance. CONCLUSIONS: A CSA guide was shown to be significantly more effective in increasing the angle of insertion of suture anchors and increased the distance of the suture anchor tip to the articular cartilage surface at the 1 o'clock position but not at the 2 or 3 o'clock position. CLINICAL RELEVANCE: The use of SSA guides can be difficult because of the osseous morphologic characteristics of the acetabular rim, leading to placement of the suture anchor away from the acetabular rim and therefore resulting in a nonanatomical refixation of the acetabular labrum. The use of a curved guide, flexible drill, and flexible suture anchor inserter may provide more precise placement of suture anchors in the acetabular rim.

Clinical three-dimensional anatomy of the femur considering navigation-aided surgery of total knee arthroplasty in Japanese patients.

PURPOSE: Few studies exist regarding sagittal alignment describing femur morphology in navigation-aided surgery. This study investigated the three-dimensional (3D) sagittal femoral alignment of the whole femur. METHODS: Seventy-three consecutive patients (59 females, 14 males, mean age: 76.1 years), yielding 140 femurs, were included in this study. A computed-tomography-based patient-specific 3D femur model was used to define a mechanical axis-based reference plane. Proximal and distal femoral axis angles (PFA, DFA) to the reference plane were measured in 3D using custom software. PFA and DFA represent the proximal and distal inclination of the femoral anatomical axis in sagittal plane, respectively. RESULTS: PFA (10.6 ± 1.5°) was greater than DFA (2.6 ± 1.6°; P < 0.0001). DFA in females (2.3 ± 1.4°) was smaller than in males (3.9 ± 1.7°; P < 0.0001). CONCLUSION: This is the first report of measurement of femoral sagittal alignment related to both 3D anatomy and decision making of femoral flexion angle using navigation surgery for total knee arthroplasty. This report shows a robust DFA measurement that could be used as a template for femoral implants flexion angle when performing both conventional and navigated total knee arthroplasty.

Computed Tomography Osteoabsorptiometry Evaluation of Cervical Endplate Subchondral Bone Mineral Density.

STUDY DESIGN: Basic Science. OBJECTIVE: Poor subchondral bone mineral density (sBMD) has been linked with subsidence of cervical interbody devices or grafts, which are traditionally placed centrally on the endplates. Considering that sBMD reflects long-term stress distributions, we hypothesize that the cervical uncovertebral joints are denser than the central endplate region. This study sought to investigate density distributions using computed tomography osteoabsorptiometry (CT-OAM). METHODS: Twelve human cervical spines from C3-C7 (60 vertebrae, 120 endplates) were imaged with CT and segmented to create 3D reconstructions. The superior and inferior endplates were isolated, and the sBMD of the whole endplate, endplate center, and uncus was evaluated using CT-OAM. Density distributions were compared across the subaxial cervical spine. RESULTS: The uncinate region of the inferior and superior endplates was significantly denser than the central endplate across all vertebral levels (P < .01). When comparing sBMD of the whole inferior and superior endplates, the superior endplate was significantly denser than the inferior endplate (P < .0001). However, the inferior uncus was denser than the superior uncus (P = .035). When assessing sBMD by vertebral level, peak densities were observed at C4 and C5, while C7 was, on average, significantly less dense than all other vertebrae. CONCLUSION: The subchondral bone of the cervical uncovertebral joints is significantly denser than the central endplates. While the superior endplate in its entirety is denser than the inferior endplate, the inverse was true for the uncovertebral joints. This study serves as a basis for future investigations of new implant designs and their implications on subsidence.

Noninvasive shape-fitting method quantifies cam morphology in femoroacetabular impingement syndrome: Implications for diagnosis and surgical planning.

There are considerable limitations associated with the standard 2D imaging currently used for the diagnosis and surgical planning of cam-type femoroacetabular impingement syndrome (FAIS). The aim of this study was to determine the accuracy of a new patient-specific shape-fitting method that quantifies cam morphology in 3D based solely on preoperative MRI imaging. Preoperative and postoperative 1.5T MRI scans were performed on n = 15 patients to generate 3D models of the proximal femur, in turn used to create the actual and the virtual cam. The actual cams were reconstructed by subtracting the postoperative from the preoperative 3D model and used as reference, while the virtual cams were generated by subtracting the preoperative 3D model from the virtual shape template produced with the shape-fitting method based solely on preoperative MRI scans. The accuracy of the shape-fitting method was tested on all patients by evaluating the agreement between the metrics of height, surface area, and volume that quantified virtual and actual cams. Accuracy of the shape-fitting method was demonstrated obtaining a 97.8% average level of agreement between these metrics. In conclusion, the shape-fitting technique is a noninvasive and patient-specific tool for the quantification and localization of cam morphology. Future studies will include the implementation of the technique within a clinically based software for diagnosis and surgical planning for cam-type FAIS.

Three-dimensional kinematic analysis of the cervical spine after anterior cervical decompression and fusion at an adjacent level: a preliminary report.

PURPOSE: Development of adjacent segment degeneration following anterior cervical decompression and fusion (ACDF) is still controversial, as adjacent-level kinematics is poorly understood. This study reports preliminary data from a high-accuracy 3D analysis technique developed for in vivo cervical kinematics. METHODS: From nine cervical spondylosis patients, four underwent single-level ACDF, and five underwent two-level ACDF using cylindrical titanium cage implant(s). Pre- and post-surgical CT scans were taken in flexion, neutral and extended positions, allowing us to compute segmental ranges of motion for rotation and translation, and 3D disc-height distributions. Differences in segmental motions and disc-height between fused and adjacent levels were analyzed with a Wilcoxon signed-rank test. Results are presented as mean ± SEM. RESULTS: The flexion/extension angular-ROM at the fusion level decreased after surgery (7.46 ± 1.17° vs. 3.14 ± 0.56°, p < 0.003). The flexion/extension angular-ROM at one caudal adjacent level to the fusion level (3.97 ± 1.29°) tended to be greater post-operatively (6.11 ± 1.44°, p = 0.074). Translation in the anterior-posterior direction during flexion/extension at the fusion level decreased after surgery (1.22 ± 0.20 mm vs. 0.32 ± 0.11 mm, p < 0.01). No differences were found in adjacent-level disc heights between both study time-points. CONCLUSIONS: This study showed increased segmental motion in flexion/extension angular-ROM at one level adjacent to ACDF. However, increases in the rotational angular-ROM were not statistically significant when cranial/caudal adjacent levels were analyzed separately. This preliminary study highlighted the capabilities of a 3D-kinematic analysis method to detect subtle changes in kinematics and disc height at the adjacent levels to ACDF. Thus, reliable evidence related to ACDF's influence on adjacent-level cervical kinematics can be collected.

Four-dimensional computed tomography evaluation of shoulder joint motion in collegiate baseball pitchers.

The purpose of this study is to evaluate the glenohumeral contact area, center of glenohumeral contact area, and center of humeral head during simulated pitching motion in collegiate baseball pitchers using four-dimensional computed tomography (4D CT). We obtained 4D CT data from the dominant and non-dominant shoulders of eight collegiate baseball pitchers during the cocking motion. CT image data of each joint were reconstructed using a 3D reconstruction software package. The glenohumeral contact area, center of glenohumeral contact area, center of humeral head, and oblateness of humeral head were calculated from 3D bone models using customized software. The center of glenohumeral contact area translated from anterior to posterior during maximum external rotation to maximum internal rotation (0.58 ± 0.63 mm on the dominant side and 0.99 ± 0.82 mm on the non-dominant side). The center of humeral head translated from posterior to anterior during maximum external rotation to maximum internal rotation (0.76 ± 0.75 mm on the dominant side and 1.21 ± 0.78 mm on the non-dominant side). The increase in anterior translation of the center of glenohumeral contact area was associated with the increase in posterior translation of the center of humeral head. Also, the increase in translation of the center of humeral head and glenohumeral contact area were associated with the increase in oblateness of the humeral head. 4D CT analyses demonstrated that the center of humeral head translated in the opposite direction to that of the center of glenohumeral contact area during external rotation to internal rotation in abduction in the dominant and non-dominant shoulders. The oblateness of the humeral head may cause this diametric translation. 4D CT scanning and the software for bone surface modeling of the glenohumeral joint enabled quantitative assessment of glenohumeral micromotion and be used for kinematic evaluation of throwing athletes.

MRI-- and CT--based metrics for the quantification of arthroscopic bone resections in femoroacetabular impingement syndrome.

The purpose of this in vitro study was to quantify the bone resected from the proximal femur during hip arthroscopy using metrics generated from magnetic resonance imaging (MRI) and computed tomography (CT) reconstructed three-dimensional (3D) bone models. Seven cadaveric hemi-pelvises underwent both a 1.5 T MRI and CT scan before and following an arthroscopic proximal femoral osteochondroplasty. The images from MRI and CT were segmented to generate 3D proximal femoral surface models. A validated 3D--3D registration method was used to compare surface--to--surface distances between the 3D models before and following surgery. The new metrics of maximum height, mean height, surface area and volume, were computed to quantify bone resected during osteochondroplasty. Stability of the metrics across imaging modalities was established through paired sample t--tests and bivariate correlation. Bivariate correlation analyses indicated strong correlations between all metrics (r = 0.728--0.878) computed from MRI and CT derived models. There were no differences in the MRI- and CT-based metrics used to quantify bone resected during femoral osteochondroplasty. Preoperative- and postoperative MRI and CT derived 3D bone models can be used to quantify bone resected during femoral osteochondroplasty, without significant differences between the imaging modalities.