Preoperative Planning and Plan Execution in Shoulder Arthroplasty

Assessing glenoid arthroplasty component positioning for surgeons utilizing surgical planning software

Influence of glenoid wear pattern on glenoid component placement accuracy in shoulder arthroplasty.

Automated muscle elongation measurement during reverse shoulder arthroplasty planning

Chapter 18 - Preoperative planning and imaging

Significant variability exists in preoperative planning software measures of glenoid morphology for shoulder arthroplasty

Commentary Iannotti et al. present a very interesting and useful investigation into the use of three-dimensional preoperative imaging and templating to assist in planning the positioning of the glenoid component during anatomic shoulder arthroplasty. Additionally, any possible benefit of patient-specific instrumentation was evaluated. To my knowledge, this is the first investigation into the clinical efficacy of this particular emerging technology. All too often, new technological innovations are rapidly adopted without any proven efficacy. This study provides evidence of the role of three-dimensional imaging and templating in the surgical treatment of patients with primary osteoarthritis. This article provides a glimpse into the near future of anatomic shoulder arthroplasty. The Materials and Methods portion of this article was appropriate to achieve the goals of the study. The study consisted of a prospective, randomized controlled trial involving a comparison of patients undergoing three-dimensional imaging and templating with patients undergoing the same imaging and templating technique with the addition of patient-specific instrumentation to assist in glenoid component positioning; a third cohort of patients who had undergone conventional two-dimensional templating was used to serve as a historical control. The retrospective latter part of this study slightly weakens its experimental design. However, given that all of the surgical procedures were performed by experienced surgeons well into their learning curve, I doubt that prospectively collecting the data on the two-dimensional group would have appreciably impacted the results. It is unclear why the authors included twenty-five patients in one group, twenty-one patients in another group, and seventeen patients in the third group. Because no patient was lost to follow-up or withdrew from the study, a better explanation of the choice of the number of the subjects to be included in each group seems warranted. This investigation was limited to a computed tomographic evaluation of glenoid component positioning at a short-term follow-up (less than three weeks). No clinical data are provided, nor would they have been useful that early in the postoperative period. The Results portion of this article yields two very important points. First, three-dimensional imaging and templating are superior to conventional two-dimensional planning in achieving the desired placement of the glenoid component in anatomic shoulder arthroplasty for primary osteoarthritis. Second, the addition of patient-specific instrumentation did not appreciably improve the surgeon’s ability to place the glenoid component in the desired location. Unfortunately, because the follow-up was too short for any meaningful clinical data to be provided, the ultimate clinical implications of this improvement in glenoid component positioning with use of three-dimensional imaging and templating compared with two-dimensional imaging and templating remains unknown. Glenoid component loosening remains a pervasive factor in the failure of anatomic shoulder arthroplasty1. Although many factors undoubtedly contribute to glenoid component failure, proper positioning of the glenoid component would seem to be critical in avoiding this complication. Iannotti et al. have shown a reproducible and accurate method to place the glenoid component in the desired position with use of three-dimensional imaging and templating and have further demonstrated the superiority of this technique over conventional two-dimensional preoperative planning. The methods of glenoid positioning used in this study would seemingly prove useful in nearly all cases of anatomic total shoulder arthroplasty. The value of this method would likely prove more beneficial in difficult cases involving substantial glenoid wear. Another potential area of applicability for the three-dimensional preoperative planning shown in this study that was not discussed by the authors is the use of this technique to preserve existing glenoid bone. Walch et al. recently demonstrated the importance of preservation of subchondral bone in preventing glenoid component failure2. Using information gained from three-dimensional imaging and templating described by Iannotti et al., the radius of curvature of the native glenoid could be established to allow the use of instrumentation and implants that do not require removal of subchondral bone to permit component placement. Importantly, this investigation did not show the benefit in using patient-specific instrumentation. In the increasingly cost-conscious environment of health care, higher cost must yield substantial benefit. The main limitation of this study was the lack of clinical correlation with the radiographic results. Although the three-dimensional preoperative planning proved to be better than two-dimensional preoperative planning at achieving the desired glenoid component positioning, the clinical relevance of this is unclear. I would encourage the authors to continue to follow these patients and to correlate clinical outcomes, complications, and revision rates with glenoid component positioning. If a relationship is subsequently demonstrated, more value will be added to this technique. Congratulations to Dr. Iannotti and his associates for their work on this study. This article shows that the future is now in using novel technology to improve our radiographic results. Time will tell if these radiographic improvements will translate into better clinical results, lower complication rates, and improved prosthetic longevity for our patients.

Technique and first clinical results of robot-assisted total knee replacement

Can preoperative planning using IRIS™ three-dimensional anatomical virtual models predict operative findings during robot-assisted partial nephrectomy?

Anatomic shoulder arthroplasty is a reliable treatment option that improves pain and functional outcomes in patients with shoulder pain, stiffness, and articular surface damage. Indications for shoulder arthroplasty include primary glenohumeral osteoarthritis, post-traumatic arthritis, rheumatoid arthritis, osteonecrosis, and post-capsulorrhaphy arthritis due to shoulder instability. Anatomic total shoulder arthroplasty (TSA) is contraindicated in those with irreparable rotator cuff tears, active infection, deltoid insufficiency, and insufficient glenoid bone stock to support a glenoid component. Hemiarthroplasty (HHR) may be considered for certain patients not eligible for anatomic TSA, including those with rotator cuff arthropathy with preserved active range of motion. A trial of medical management is always reasonable prior to proceeding with shoulder arthroplasty. Preoperative planning includes a thorough history and physical exam, radiographs, laboratory studies, and advanced imaging in some cases. Appropriate preoperative planning can help improve outcomes and reduce complications.

Assessment of 3D automated software to predict postoperative impingement free range of motion after reverse shoulder arthroplasty

Longevity of total anatomic and reversed shoulder arthroplasty largely depends on accurate correction of glenoid deformity and correct positioning and fixation of the glenoid component. However, the morphology of the scapula is inconsistent, varying degrees of osteoarthritis cause numerous anatomic changes, and standard 2-dimensional imaging and standard surgical instrumentation are imprecise for preoperative planning and execution of glenoid reconstruction. Recently, various authors have shown that preoperative 3-dimensional surgical planning and computer navigation technology may increase the accuracy and repeatability of the implantation of the glenoid component, especially for the position and orientation of the glenosphere and screws in reversed arthroplasty. These novel techniques may allow the surgeon to better define the preoperative deformity, select the optimal implant position, and then accurately execute the plan at the time of surgery. Future studies are needed to determine the long-term effect on functional outcome and cost-effectiveness of computer-assisted technology in shoulder arthroplasty.

The number of shoulder arthroplasties performed in the United States has more than doubled in the last decade. Additionally, there has been a trend toward use of reverse total shoulder arthroplasty and minimally invasive surgical techniques, such as resurfacing humeral head arthroplasty. Thus radiologists will more frequently encounter imaging of shoulder arthroplasty and these new designs. Successful postoperative radiologic evaluation of shoulder reconstructions requires an understanding of their fundamental hardware design, physiologic objective, preoperative imaging assessment, normal postoperative radiologic appearance, and findings and types of complication. This article discusses the designs of prostheses used around the shoulder joint, delineates indications and alternatives for each of the different types of hardware, reviews radiographic and cross-sectional preoperative imaging of shoulder arthroplasty, illustrates normal postoperative imaging findings and measurements, and provides examples of hardware complications.

Implant Removal in Revision Arthroplasty: A Tour de Force

(1) Background: The three-dimensional printing (3DP) technique has been reported to be of great utility in spine surgery. The purpose of this study is to report the clinical application of personalized preoperative digital planning and a 3DP guidance template in the treatment of severe and complex adult spinal deformity. (2) Methods: eight adult patients with severe rigid kyphoscoliosis were given personalized surgical simulation based on the preoperative radiological data. Guidance templates for screw insertion and osteotomy were designed and manufactured according to the planning protocol and used during the correction surgery. The perioperative, and radiological parameters and complications, including surgery duration, estimated blood loss, pre- and post-operative cobb angle, trunk balance, and precision of osteotomy operation with screw implantation were collected retrospectively and analyzed to evaluate the clinical efficacy and safety of this technique. (3) Results: Of the eight patients, the primary pathology of scoliosis included two adult idiopathic scoliosis (ADIS), four congenital scoliosis (CS), one ankylosing spondylitis (AS), and one tuberculosis (TB). Two patients had a previous history of spinal surgery. Three pedicle subtraction osteotomies (PSOs) and five vertebral column resection (VCR) osteotomies were successfully performed with the application of the guide templates. The main cobb angle was corrected from 99.33° to 34.17°, and the kyphosis was corrected from 110.00° to 42.00°. The ratio of osteotomy execution and simulation was 97.02%. In the cohort, the average screw accuracy was 93.04%. (4) Conclusions: The clinical application of personalized digital surgical planning and precise execution via 3D printing guidance templates in the treatment of severe adult rigid deformity is feasible, effective, and easily generalizable. The preoperative osteotomy simulation was executed with high precision, utilizing personalized designed guidance templates. This technique can be used to reduce the surgical risk and difficulty of screw placement and high-level osteotomy.

Chapter 7 - Preoperative planning and imaging