Surgical training integrates several years of didactic learning, simulation, mentorship, and hands-on experience. Challenges include stress, technical demands, and new technologies. Orthopedic education often uses static materials like books, images, and videos, lacking interactivity. This study compares a new interactive photorealistic 3D visualization to 2D videos for learning total hip arthroplasty. In a randomized controlled trial, participants (students and residents) were evaluated on spatial awareness, tool placement, and task times in a simulation. Results show that interactive photorealistic 3D visualization significantly improved scores, with residents and those with prior 3D experience performing better. These results emphasize the potential of the interactive photorealistic 3D visualization to enhance orthopedic training.
Background Computer-assisted solutions are changing surgical practice continuously. One of the most disruptive technologies among the computer-integrated surgical techniques is Augmented Reality (AR). While Augmented Reality is increasingly used in several medical specialties, its potential benefit in orthopedic surgery is not yet clear. The purpose of this article is to provide a systematic review of the current state of knowledge and the applicability of AR in orthopedic surgery. Methods A systematic review of the current literature was performed to find the state of knowledge and applicability of AR in Orthopedic surgery. A systematic search of the following three databases was performed: “PubMed”, “Cochrane Library” and “Web of Science”. The systematic review followed the Preferred Reporting Items on Systematic Reviews and Meta-analysis (PRISMA) guidelines and it has been published and registered in the international prospective register of systematic reviews (PROSPERO). Results 31 studies and reports are included and classified into the following categories: Instrument / Implant Placement, Osteotomies, Tumor Surgery, Trauma, and Surgical Training and Education . Quality assessment could be performed in 18 studies. Among the clinical studies, there were six case series with an average score of 90% and one case report, which scored 81% according to the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC). The 11 cadaveric studies scored 81% according to the QUACS scale (Quality Appraisal for Cadaveric Studies). Conclusion This manuscript provides 1) a summary of the current state of knowledge and research of Augmented Reality in orthopedic surgery presented in the literature, and 2) a discussion by the authors presenting the key remarks required for seamless integration of Augmented Reality in the future surgical practice. Trial registration PROSPERO registration number: CRD42019128569 .
Nutritional status is a strong predictor of postoperative outcomes and is recognized as an important component of surgical recovery programs. Adequate nutritional consumption is essential for addressing the surgical stress response and mitigating the loss of muscle mass, strength, and functionality. Especially in older patients, inadequate protein can lead to significant muscle atrophy, leading to a loss of independence and increased mortality risk. Current nutritional recommendations for surgery primarily focus on screening and prevention of malnutrition, pre-surgical fasting protocols, and combating post-surgical insulin resistance, while recommendations regarding macronutrient composition and timing around surgery are less established. The goal of this review is to highlight oral nutrition strategies that can be implemented leading up to and following major surgery to minimize atrophy and the resultant loss of functionality. The role of carbohydrate and especially protein/essential amino acids in combating the surgical stress cascade and supporting recovery are discussed. Practical considerations for nutrient timing to maximize oral nutritional intake, especially during the immediate pre- and post- surgical periods, are also be discussed.
Background: Delirium is a critical postoperative complication in older patients. Based on the hypothesis that intraoperative dexmedetomidine sedation would lower postoperative delirium than propofol sedation would, the authors compared the incidence of postoperative delirium in older adults, using the mentioned sedatives. Methods: This double-blinded, randomized controlled study included 748 patients, aged 65 yr or older, who were scheduled for elective lower extremity orthopedic surgery, between June 2017 and October 2021. Patients were randomized equally into two groups in a 1:1 ratio according to the intraoperative sedative used (dexmedetomidine vs. propofol). The postoperative delirium incidence was considered the primary outcome measure; it was determined using the confusion assessment method, on the first three postoperative days. The mean arterial pressure and heart rate were evaluated as secondary outcomes. Results: The authors enrolled 732 patients in the intention-to-treat analyses. The delirium incidence was lower in the dexmedetomidine group than in the propofol group (11 [3.0%] vs. 24 [6.6%]; odds ratio, 0.42; 95% CI, 0.201 to 0.86; P = 0.036). During sedation, the mean arterial pressure (median [interquartile range] mmHg) was higher in the dexmedetomidine group (77 [71 to 84]) than in the propofol group (74 [69 to 79]; P < 0.001); however, it significantly fell lower (74 [68 to 80]) than that of the propofol group (80 [74 to 87]) in the postanesthesia care unit (P < 0.001). Lower heart rates (beats/min) were recorded with the use of dexmedetomidine than with propofol, both during sedation (60 [55 to 66] vs. 63 [58 to 70]) and in the postanesthesia care unit (64 [58 to 72] vs. 68 [62–77]; P < 0.001). Conclusions: Dexmedetomidine showed a lower incidence of postoperative delirium than propofol in healthy older adults undergoing lower extremity orthopedic surgery. A randomized double-blinded study of 732 patients 65 yr or older, scheduled for elective lower extremity orthopedic surgery under spinal anesthesia, were randomized to dexmedetomidine or propofol sedation. Patients receiving dexmedetomidine sedation had a lower incidence of delirium when compared to sedation with propofol, suggesting benefit of dexmedetomidine.
Background:
Treatment of complex nonunion is tough in the context of previous surgeries, recurrent infection, shortening, bone loss, associated bone deformities, and joint stiffness. Various treatments are available, including the Ilizarov ring fixator which is well established, but poor patient compliance and the bulky fixator push us to conduct another method of bone transport and distraction osteogenesis by monorail fixator. We conducted a study on 26 patients to know the outcome of monorail fixator in the treatment of complex nonunion in terms of rate of union, duration of treatment, and frequency of complications.
Materials and Methods:
The study comprised 26 patients, 22 of whom were male and 4 were female. Majority of cases landing up as complex nonunion were as a result of road traffic accidents. Two-thirds of the patients presenting to us had an infection in the form of discharging sinus or quiescent sinus, while one-third of the patients had aseptic nonunion. Majority of the patients had an external fixator or infected implant at the time of presentation. Corticotomy was done in almost all (96.2%) of the patients.
Results:
Out of 26 patients, treatment was completed in 25 patients, and one patient was lost to follow-up. The mean treatment duration was 11.31 months ranging from 5 months to 21 months. The mean follow-up duration was 12.8 months ranging from 7 months to 22 months. Results were assessed according to the ASAMI scoring system. Bone results were excellent in 19 (76%), good in 3 (12%), fair in 2 (8%), and failure in 1 (4%) cases. Functional results were excellent in 20 (80%), good in 2 (8%), and fair in 2 (8%). One case was declared a failure. Pin tract infection was the most common complication. Other complications encountered were pain during distraction, pin loosening, and joint stiffness. There was no significant angular deviation (>15°) in any case. Neurovascular complications, joint subluxation, or fracture of regenerate was not seen in any of the cases. Delayed maturation of the regenerate was dealt with by slowing or stopping the distraction for some days.
Conclusion:
It is concluded that the limb reconstruction system (LRS) (monorail fixator) is less bulky and relatively simple to apply, patient compliance is very good, operating time is considerably less, and no preoperative frame assembly is required. Good patient satisfaction, less pain during bone transport, less fluoroscopy exposure, and easy care management of concomitant soft-tissue injury are added advantages of LRS (monorail fixator).
Nitchanant Kitcharanant, Prangmalee Leurcharusmee, Pichitchai Atthakomol
et al.
Abstract Background Even with the great advancements in recent years in total knee arthroplasty (TKA), some patients continue to have persistent postsurgical pain (PPSP). The advantages of systemic corticosteroids in the perioperative context have been further supported by previously published trials. However, the impact of dexamethasone on the intensity of post-TKA PPSP is still unclear. We aimed to investigate its effect on the degree of PPSP and compare that with a placebo. Methods In this randomized, double-blind, placebo-controlled study, 48 patients undergoing unilateral TKA were given intravenous dexamethasone 10 mg or saline just before spinal anesthesia was induced, and they also received two additional doses of dexamethasone 10 mg or saline 24 and 48 h after surgery. A standardized, multimodal analgesic regimen was administered to each patient. The modified WOMAC pain scores at 12 weeks postoperative were the main outcome. The secondary outcomes included pain during a walk of five meters, pain during active knee flexion at 45 degrees, maximum pain at rest during the previous 24 h, nausea visual analogue scale values, and use of rescue opioid and antiemetic medications. Results There was no difference in modified WOMAC pain scores 12 weeks after surgery between patients who received and did not receive perioperative dexamethasone. At 24, 30, 48, 54, and 72 h following surgery, the dexamethasone group experienced considerably less pain during a five-meter walk and during 45 degrees active knee flexion (p < 0.01). At postoperative 0–24, 24–48, and 48–72 h, the dexamethasone group experienced less maximal pain at rest (p < 0.01). The dexamethasone group also had less visual analogue scale scores for nausea at 6, 24, 30, 48, and 54 h after surgery (p < 0.02). During the first 0–24 and 24–48 h, the dexamethasone group consumed fewer opioids and antiemetic medications (p < 0.01). All patients showed no signs of wound complications. Conclusions When compared to a placebo at 12 weeks after TKA, intravenous dexamethasone did not reduce PPSP. Nevertheless, early postoperative pain was relieved by perioperative intravenous dexamethasone, which also decreased the need for opioid and antiemetic medications and decreased postoperative nausea and vomiting. Trial registration NCT02760459.
Orthopedic surgery, Diseases of the musculoskeletal system
Periacetabular osteotomy (PAO) is an effective approach for the surgical treatment of developmental dysplasia of the hip (DDH). However, due to the complex anatomical structure around the hip joint and the limited field of view (FoV) during the surgery, it is challenging for surgeons to perform a PAO surgery. To solve this challenge, we propose a robot-assisted, augmented reality (AR)-guided surgical navigation system for PAO. The system mainly consists of a robot arm, an optical tracker, and a Microsoft HoloLens 2 headset, which is a state-of-the-art (SOTA) optical see-through (OST) head-mounted display (HMD). For AR guidance, we propose an optical marker-based AR registration method to estimate a transformation from the optical tracker coordinate system (COS) to the virtual space COS such that the virtual models can be superimposed on the corresponding physical counterparts. Furthermore, to guide the osteotomy, the developed system automatically aligns a bone saw with osteotomy planes planned in preoperative images. Then, it provides surgeons with not only virtual constraints to restrict movement of the bone saw but also AR guidance for visual feedback without sight diversion, leading to higher surgical accuracy and improved surgical safety. Comprehensive experiments were conducted to evaluate both the AR registration accuracy and osteotomy accuracy of the developed navigation system. The proposed AR registration method achieved an average mean absolute distance error (mADE) of 1.96 ± 0.43 mm. The robotic system achieved an average center translation error of 0.96 ± 0.23 mm, an average maximum distance of 1.31 ± 0.20 mm, and an average angular deviation of 3.77 ± 0.85°. Experimental results demonstrated both the AR registration accuracy and the osteotomy accuracy of the developed system.
Donna J. Oeffinger, PhD, Henry Iwinski, MD, Vishwas Talwalkar, MD
et al.
Background: Despite widespread usage of the SRS-22r questionnaire (Scoliosis Research Society Questionnaire-22r), the English version has only sparingly been subjected to analysis using modern psychometric techniques for patients with adolescent idiopathic scoliosis (AIS). The study purpose was to improve interpretation and clinical utility of the SRS-22r for adolescents with AIS by generating additional robust evidence, using modern statistical techniques. Questions about (1) Structure and (2) Item and Scale Functioning are addressed and interpreted for clinicians and researchers. Methods: This retrospective case review analyzed SRS-22r data collected from 1823 patients (mean age 14.9±2.2years) with a primary diagnosis of AIS who clinically completed an SRS-22r questionnaire.Individual SRS-22r questions and domain scores were retrieved through data queries. Patient information collected through chart review included diagnosis, age at assessment, sex, race and radiographic parameters. From 6044 SRS-22r assessments, 1 assessment per patient was randomly selected. Exploratory structural equation modeling (ESEM) and item response theory (IRT) techniques were used for data modeling, item calibration, and reliability assessment. Results: ESEM demonstrated acceptable fit to the data: χ2 (130)=343.73, p<.001; RMSEA=0.035; CFI=0.98; TLI=0.96; SRMR=0.02. Several items failed to adequately load onto their assigned factor. Item fit was adequate for all items except SRSq10 (Self-Image), SRSq16 (Mental Health), and SRSq20 (Mental Health). IRT models found item discriminations are within normal levels for items in psychological measures, except items SRSq1 (pain), SRSq2 (pain), and SRSq16 (mental health). Estimated reliability of the Function domain (ρ=0.69) was low, however, Pain, Self-Image and Mental Health domains exhibited high (ρ>0.80) reliability. Conclusions: Modern psychometric assessment of the SRS-22r, in adolescent patients with AIS, are presented and interpreted to assist clinicians and researchers in understanding its strengths and limitations. Overall, the SRS-22r demonstrated good psychometric properties in all domains except function. Cautious interpretation of the total score is suggested, as it does not reflect a single HRQoL construct.
Orthopedic surgery, Neurology. Diseases of the nervous system
The recent Segment Anything Model (SAM) 2 has demonstrated remarkable foundational competence in semantic segmentation, with its memory mechanism and mask decoder further addressing challenges in video tracking and object occlusion, thereby achieving superior results in interactive segmentation for both images and videos. Building upon our previous empirical studies, we further explore the zero-shot segmentation performance of SAM 2 in robot-assisted surgery based on prompts, alongside its robustness against real-world corruption. For static images, we employ two forms of prompts: 1-point and bounding box, while for video sequences, the 1-point prompt is applied to the initial frame. Through extensive experimentation on the MICCAI EndoVis 2017 and EndoVis 2018 benchmarks, SAM 2, when utilizing bounding box prompts, outperforms state-of-the-art (SOTA) methods in comparative evaluations. The results with point prompts also exhibit a substantial enhancement over SAM's capabilities, nearing or even surpassing existing unprompted SOTA methodologies. Besides, SAM 2 demonstrates improved inference speed and less performance degradation against various image corruption. Although slightly unsatisfactory results remain in specific edges or regions, SAM 2's robust adaptability to 1-point prompts underscores its potential for downstream surgical tasks with limited prompt requirements.
Background: Radiography (X-rays) is the dominant modality in orthopedics, and improving the interpretation of radiographs is clinically relevant. Machine learning (ML) has revolutionized data analysis and has been applied to medicine, with some success, in the form of natural language processing (NLP) and artificial neural networks (ANN). Latent Dirichlet allocation (LDA) is an NLP method that automatically categorizes documents into topics. Successfully applying ML to orthopedic radiography could enable the creation of computer-aided decision systems for use in the clinic. We studied how an automated ML pipeline could classify orthopedic trauma radiographs from radiologist reports. Methods: Wrist and ankle radiographs from Danderyd Hospital in Sweden taken between 2002 and 2015, with radiologist reports. LDA was used to create image labels for radiographs from the radiologist reports. Radiographs and labels were used to train an image recognition ANN. The ANN outcomes were manually reviewed to get an accurate estimate of the method's utility and accuracy. Results: Image Labels generated via LDA could successfully train the ANN. The ANN reached an accuracy between 91% and 60% compared to a gold standard, depending on the label. Conclusions: We found that LDA was unsuited to label orthopedic radiographs from reports with high accuracy. However, despite this, the ANN could learn to detect some features in radiographs with high accuracy. The study also illustrates how ML and ANN can be applied to medical research.
Two Dehn surgeries on a knot are called cosmetic if they yield homeomorphic three-manifolds. We show for a certain family of null-homologous knots in any closed orientable three-manifold, if the knot admits cosmetic surgeries with a pair of positive surgery coefficients, then the coefficients are both greater than $1$. In addition, for this family of knots, we show that $1/q$ Dehn surgery for $q$ at least $2$ is not homeomorphic to the original three-manifold. The proofs of these results use the mapping cone formula for the Heegaard Floer homology of Dehn surgery in terms of the knot Floer homology of the knot; we provide a new proof of this formula for integer surgeries in $\text{Spin}^c$ structures with nontorsion first Chern class.
Virtual Reality technology, when integrated with Surgical Digital Twins (SDTs), offers significant potential in medical training and surgical planning. We present SurgTwinVR, a VR application that immerses users within an SDT and enables them to navigate a high-fidelity virtual replica of the surgical environment. SurgTwinVR is the first VR application to utilize a dynamic 3D environment that is a clone of a real surgery, encompassing the entire surgical scene, including the surgeon, anatomy, and instruments. Our system utilizes a SDT with important improvements for real-time rendering and features to showcase the potential benefits of such an application in surgical education.
Surgery on a knot in $S^3$ is said to be an alternating surgery if it yields the double branched cover of an alternating link. The main theoretical contribution is to show that the set of alternating surgery slopes is algorithmically computable and to establish several structural results. Furthermore, we calculate the set of alternating surgery slopes for many examples of knots, including all hyperbolic knots in the SnapPy census. These examples exhibit several interesting phenomena including strongly invertible knots with a unique alternating surgery and asymmetric knots with two alternating surgery slopes. We also establish upper bounds on the set of alternating surgeries, showing that an alternating surgery slope on a hyperbolic knot satisfies $|p/q| \leq 3g(K)+4$. Notably, this bound applies to lens space surgeries, thereby strengthening the known genus bounds from the conjecture of Goda and Teragaito.
Casey M. O’Connor, A. Anoushiravani, Matthew R. DiCaprio
et al.
Background The economic effects of the COVID-19 crisis are not like anything the U.S. health care system has ever experienced. Methods As we begin to emerge from the peak of the COVID-19 pandemic, we need to plan the sustainable resumption of elective procedures. We must first ensure the safety of our patients and surgical staff. It must be a priority to monitor the availability of supplies for the continued care of patients suffering from COVID-19. As we resume elective orthopedic surgery and total joint arthroplasty, we must begin to reduce expenses by renegotiating vendor contracts, use ambulatory surgery centers and hospital outpatient departments in a safe and effective manner, adhere to strict evidence-based and COVID-19–adjusted practices, and incorporate telemedicine and other technology platforms when feasible for health care systems and orthopedic groups to survive economically. Results The return to normalcy will be slow and may be different than what we are accustomed to, but we must work together to plan a transition to a more sustainable health care reality which accommodates a COVID-19 world. Conclusion Our goal should be using these lessons to achieve a healthy and successful 2021 fiscal year.
Laith K. Hasan, Aryan Haratian, Michael Kim
et al.
Abstract One emerging technology with the potential to improve and further transform the field of orthopaedic surgery is virtual reality (VR). VR has been explored and used in many different specialties with clinical applications, such as psychiatric therapy, pain management, rehabilitation, and traumatic brain injury. Recent studies have suggested that the use of VR during the training of orthopaedic surgery residents produces similar or improved surgical performance by residents. This is an area where VR can provide a tremendous benefit to the field of orthopaedic surgery, as it offers a safe and accessible complement to orthopaedic surgical training outside of the operating room (OR) and without involving patients directly. This review will elucidate the current state of virtual reality use in the training of orthopaedic surgeons and highlight key benefits and challenges in its application as a training resource.
Andrea Lavorato, Gelsomina Aruta, Raffaele De Marco
et al.
Abstract Background Peripheral nerve injuries (PNIs) include several conditions in which one or more peripheral nerves are damaged. Trauma is one of the most common causes of PNIs and young people are particularly affected. They have a significant impact on patients’ quality of life and on the healthcare system, while timing and type of surgical treatment are of the utmost importance to guarantee the most favorable functional recovery. To date, several different classifications of PNIs have been proposed, most of them focusing on just one or few aspects of these complex conditions, such as type of injury, anatomic situation, or prognostic factors. Current classifications do not enable us to have a complete view of this pathology, which includes diagnosis, treatment choice, and possible outcomes. This fragmentation sometimes leads to an ambiguous definition of PNIs and the impossibility of exchanging crucial information between different physicians and healthcare structures, which can create confusion in the choice of therapeutic strategies and timing of surgery. Materials The authors retrospectively analyzed a group of 24 patients treated in their center and applied a new classification for PNI injuries. They chose (a) five injury-related factors, namely nerve involved, lesion site, nerve type (whether motor, sensory or mixed), surrounding tissues (whether soft tissues were involved or not), and lesion type—whether partial/in continuity or complete. An alphanumeric code was applied to each of these classes, and (b) four prognostic codes, related to age, timing, techniques, and comorbidities. Results An alphanumeric code was produced, similar to that used in the AO classification of fractures. Conclusions The authors propose this novel classification for PNIs, with the main advantage to allow physicians to easily understand the characteristics of nerve lesions, severity, possibility of spontaneous recovery, onset of early complications, need for surgical treatment, and the best surgical approach. Level of evidence: according to the Oxford 2011 level of evidence, level 2.
Madalin Bulzan, Simona Cavalu, Amir Mohamed Abdelhamid
et al.
Background. In orthopedics, the patients’ quality of life relative to the preoperative and postoperative phase is referred with a low impact compared to other branches of medicine. In this context, our interest focused on assessing the quality of life in patients with traumatic and non-traumatic coxarthrosis by longitudinally following the evolution of the patients. Materials and Methods. The well-established instrument Short Form Survey SF-36 was applied in a retrospective study, conducted on a cohort of 203 participants who underwent THA (Total Hip Arthroplasty). Statistical analysis was generated using GraphPad Prism (version 9.5.1). Results. In the pre-operative phase, physical functioning was more affected in participants with traumatic coxarthrosis, while fatigue was specific to nontraumatic coxarthrosis. Emotional well-being and social functioning were high in patients with traumatic coxarthrosis. One month after surgery, we recorded an increased physical functioning and improvement in the perception of the ability to exercise roles in non-traumatic group. Energy/vitality and general health and wellbeing were at high level in traumatic group, 1st month post-surgery, although pain was still frequent. Age was the sole strong independent predictor of postoperative physical functioning in the traumatic group, while in the non-traumatic group, we identified gender, age, symptoms and type of prosthesis as strong predictors of postoperative physical functioning. The overall results related to daily living activities indicated that the traumatic group displayed more favorable post-surgery evolution and higher autonomy compared to the non-traumatic one. Conclusions. We conclude that SF-36 questionnaire is a specific, useful and inexpensive tool for evaluating the outcomes of orthopedic treatment and patients’ evolution after arthroplasty, especially in terms of functional outcome scores relative to coxarthrosis etiology.
Bedros Taslakian, Larry E. Miller, Tarub S. Mabud
et al.
Objective: Genicular artery embolization (GAE) is a novel, minimally invasive procedure for treatment of knee osteoarthritis (OA). This meta-analysis investigated the safety and effectiveness of this procedure. Design: Outcomes of this systematic review with meta-analysis were technical success, knee pain visual analog scale (VAS; 0–100 scale), WOMAC Total Score (0–100 scale), retreatment rate, and adverse events. Continuous outcomes were calculated as the weighted mean difference (WMD) versus baseline. Minimal clinically important difference (MCID) and substantial clinical benefit (SCB) rates were estimated in Monte Carlo simulations. Rates of total knee replacement and repeat GAE were calculated using life-table methods. Results: In 10 groups (9 studies; 270 patients; 339 knees), GAE technical success was 99.7%. Over 12 months, the WMD ranged from −34 to −39 at each follow-up for VAS score and −28 to −34 for WOMAC Total score (all p < 0.001). At 12 months, 78% met the MCID for VAS score; 92% met the MCID for WOMAC Total score, and 78% met the SCB for WOMAC Total score. Higher baseline knee pain severity was associated with greater improvements in knee pain. Over 2 years, 5.2% of patients underwent total knee replacement and 8.3% received repeat GAE. Adverse events were minor, with transient skin discoloration as the most common (11.6%). Conclusions: Limited evidence suggests that GAE is a safe procedure that confers improvement in knee OA symptoms at established MCID thresholds. Patients with greater knee pain severity may be more responsive to GAE.