Aims. Complex elbow fracture-dislocations often result in suboptimal outcomes and necessitate a thorough understanding of injury patterns to guide effective management and reduce adverse sequelae. The Wrightington Classification System (WCS) offers a comprehensive approach and considers both bony and soft-tissue disruption, providing clearer guidance for treatment. This is the first external study to assess the reliability of the WCS for elbow fracture-dislocations. Methods. A blinded study of patients with elbow fracture-dislocations at a single institution between December 2014 and December 2022 was conducted. Five assessors with a range of experience, including orthopaedic surgeons and radiologists, independently classified injuries using the WCS across three image methods: plain radiograph, 2D CT, and 2D and 3D CT reconstruction images, on two occasions with an eight-week interval. Interobserver and intraobserver reliability were evaluated using kappa statistics and the Landis and Koch criteria. Results. A total of 73 patients were included in the study. Interobserver reliability was moderate, with mean kappa values of 0.518 (95% CI 0.499 to 0.537), 0.557 (95% CI 0.537 to 0.577), and 0.582 (95% CI 0.562 to 0.601), for radiographs, 2D CT, and 2D and 3D CT reconstructions, respectively. Intraobserver agreement was substantial (mean kappa 0.695 (SE 0.067), 0.729 (SE 0.071), and 0.777 (SE 0.070) for radiographs, 2D CT, and 3D CT reconstructions, respectively). Conclusion. The WCS is a reliable and valuable tool for characterizing elbow fracture-dislocations and guiding surgical interventions. This study found moderate reliability in using the WCS, with higher reliability with combined 2D and 3D CT imaging. Further refinement within the WCS in differentiating between coronoid avulsions, basal, anteromedial, and/or anterolateral facet injuries may help improve reliability and reproducibility. Cite this article: Bone Joint J 2025;107-B(2):188–192

Aims. The Wrightington classification system of fracture-dislocations of the elbow divides these injuries into six subtypes depending on the involvement of the coronoid and the radial head. The aim of this study was to assess the reliability and reproducibility of this classification system. Methods. This was a blinded study using radiographs and CT scans of 48 consecutive patients managed according to the Wrightington classification system between 2010 and 2018. Four trauma and orthopaedic consultants, two post CCT fellows, and one speciality registrar based in the UK classified the injuries. The seven observers reviewed preoperative radiographs and CT scans twice, with a minimum four-week interval. Radiographs and CT scans were reviewed separately. Inter- and intraobserver reliability were calculated using Fleiss and Cohen kappa coefficients. The Landis and Koch criteria were used to interpret the strength of the kappa values. Validity was assessed by calculating the percentage agreement against intraoperative findings. Results. Of the 48 patients, three (6%) had type A injury, 11 (23%) type B, 16 (33%) type B+, 16 (33%) Type C, two (4%) type D+, and none had a type D injury. All 48 patients had anteroposterior (AP) and lateral radiographs, 44 had 2D CT scans, and 39 had 3D reconstructions. The interobserver reliability kappa value was 0.52 for radiographs, 0.71 for 2D CT scans, and 0.73 for a combination of 2D and 3D reconstruction CT scans. The median intraobserver reliability was 0.75 (interquartile range (IQR) 0.62 to 0.79) for radiographs, 0.77 (IQR 0.73 to 0.94) for 2D CT scans, and 0.89 (IQR 0.77 to 0.93) for the combination of 2D and 3D reconstruction. Validity analysis showed that accuracy significantly improved when using CT scans (p = 0.018 and p = 0.028 respectively). Conclusion. The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. CT scans are significantly more accurate than radiographs when identifying the pattern of injury, with good intra- and interobserver reproducibility. Cite this article: Bone Joint J 2020;102-B(8):1041–1047

Background. Radiological and clinical results of total shoulder arthroplasty are dependent upon ability to accurately measure and correct glenoid version. There are a variety of imaging modalities and computer-assisted reconstruction programmes that are employed with varying degrees of success. We have compared three freely available modalities: unformatted 2D CT; formatted 2D CT; and 3D CT reconstructions. Methods. A retrospective analysis of 20 shoulder CT scans was performed. Glenoid version was measured at the estimated mid-point of the glenoid from unformatted 2D CT scans (Scapula body method) and again following formatting of 2D CT scans in the plane of the scapula (Friedman method). 3D scapula reconstructions were also performed by downloading CT DICOM images to OSIRIX 6 and plotting ROI points on Friedman's axis to most accurately define glenoid version. Both measurements taken from 2D CT were compared to those from 3D CT. Eleven CT scans were of male patients, 9 female. Mean age was 55.2 years (Range: 23–77 years). Fourteen scans were performed for trauma, 6 for arthroplasty. Twelve scans were of the left shoulder. Results. Mean glenoid version as measured on: unformatted 2D CT was −4.51 degrees (−29.67 – 7.22 degrees); formatted 2D CT was −2.04 degrees (−36.96 – 9.72 degrees); and on 3D reconstructions was −3.01 degrees (−32.57 – 14.33 degrees). Sixty percent of measurements taken on formatted 2D CT were within 3 degrees of those taken on 3D reconstructions, with 85% within 5 degrees. This proportion fell to 30% and 50% respectively on unformatted 2D CT. Discussion. In this small study measurements of glenoid version taken on formatted 2D CT demonstrated greater accuracy than unformatted 2D CT when comparing to 3D reconstruction measurements as the gold standard. Although we demonstrated no significant statistical difference between measurements in this pilot study we believe significance will be obtained as we increase our sample size

Aims. We quantitatively compared the 3D bone density distributions on CT scans performed on scaphoid waist fractures subacutely that went on to union or nonunion, and assessed whether 2D CT evaluations correlate with 3D bone density evaluations. Methods. We constructed 3D models from 17 scaphoid waist fracture CTs performed between four to 18 weeks after fracture that did not unite (nonunion group), 17 age-matched scaphoid waist fracture CTs that healed (union group), and 17 age-matched control CTs without injury (control group). We measured the 3D bone density for the distal and proximal fragments relative to the triquetrum bone density and compared findings among the three groups. We then performed bone density measurements using 2D CT and evaluated the correlation with 3D bone densities. We identified the optimal cutoff with diagnostic values of the 2D method to predict nonunion with receiver operating characteristic (ROC) curves. Results. In the nonunion group, both the distal (100.2%) and proximal (126.6%) fragments had a significantly higher bone density compared to the union (distal: 85.7%; proximal: 108.3%) or control groups (distal: 91.6%; proximal: 109.1%) using the 3D bone density measurement, which were statistically significant for all comparisons. 2D measurements were highly correlated to 3D bone density measurements (Spearman’s correlation coefficient (R) = 0.85 to 0.95). Using 2D measurements, ROC curve analysis revealed the optimal cutoffs of 90.8% and 116.3% for distal and proximal fragments. This led to a sensitivity of 1.00 if either cutoff is met and a specificity of 0.82 when both cutoffs are met. Conclusion. Using 3D modelling software, nonunions were found to exhibit bone density increases in both the distal and proximal fragments in CTs performed between four to 18 weeks after fracture during the course of treatment. 2D bone density measurements using standard CT scans correlate well with 3D models. In patients with scaphoid fractures, CT bone density measurements may be useful in predicting the likelihood of nonunion. Cite this article: Bone Joint J 2020;102-B(9):1200–1209

An adult acquired flatfoot deformity (AAFD) is a complex 3D deformity. Surgical correction consists of a medial calcaneal osteotomy (MCO) but shows limitations due to the current 2D assessment. Therefore, the aim is to determine the influence of an MCO on the longitudinal foot arch assessed by 2D and 3D weightbearing CT (WBCT). Seventeen patients with a mean age of 44,5 years (range 18–66 yrs) were retrospectively included. MCO was indicated in a stage II AAFD (N=15) and a post-traumatic valgus deformity (N=2). Pre- and post-operative imaging was obtained from a WBCT. The height of the longitudinal foot arch was measured as the distance from the navicular tuberositas to the floor (Navicular Height, NH) on 2D CT images (NH. 2D. ) and computed on 3D CT data (NH. 3D. ). Additionally, 3D assessment could compute the degree of exorotation (α) of the navicular bone towards the vertical axis. The mean pre-operative NH. 2D. and NH. 3D. were respectively 29.57mm ± 7.59 and 28.34mm ± 6.51. These showed to be statistically different from the mean post-operative NH. 2D. and NH. 3D. , respectively 31.62mm ± 6.69 and 31.67mm ± 6.47 (p < 0,001). A statistical difference was also found when comparing the mean degree of exorotation in pre- and post-operative, respectively: α. pre. =14.08° ± 4,92 and the α. post. =19,88° ± 3.50 (p < 0,001). This study demonstrates a significant correction of the longitudinal foot arch after a MCO. The novelty is attributed to the accurate degree of rotation assessment using WBCT. This information could be assistive to optimise a pre-operative planning

Introduction. The degree of glenoid bone loss associated with primary glenohumeral osteoarthritis can influence the type of glenoid implant selected and its placement in total shoulder arthroplasty (TSA). The literature has demonstrated inaccurate glenoid component placement when using standard instruments and two-dimensional (2D) imaging without templating, particularly as the degree of glenoid deformity or bone loss worsens. Published results have demonstrated improved accuracy of implant placement when using three-dimensional (3D) computed tomography (CT) imaging with implant templating and patient specific instrumentation (PSI). Accurate placement of the glenoid component in TSA is expected to decrease component malposition and better correct pathologic deformity in order to decrease the risk of component loosening and failure over time. Different types of PSI have been described. Some PSI use 3D printed single use disposable instrumentation, while others use adjustable and reusable-patient specific instrumentation (R-PSI). However, no studies have directly compared the accuracy of different types of PSI in shoulder arthroplasty. We combined our clinical experience and compare the accuracy of glenoid implant placement with five different types of instrumentation when using 3D CT imaging, preoperative planning and implant templating in a series of 173 patients undergoing primary TSA. Our hypothesis was that all PSI technologies would demonstrate equivalent accuracy of implant placement and that PSI would show the most benefit with more severe glenoid deformity. Discussion and Conclusions. We demonstrated no consistent differences in accuracy of 3D CT preoperative planning and templating with any type of PSI used. In Groups 1 and 2, standard instrumentation was used in a patient specific manner defined by the software and in Groups 3, 4, and 5 a patient specific instrument was used. In all groups, the two surgeons were very experienced with use of the 3D CT preoperative planning and templating software and all of the instrumentation prior to starting this study, as well as very experienced with shoulder arthroplasty. This is a strength of the study when defining the efficacy of the technology, but limits the generalizability of the findings when considering the effectiveness of the technology with surgeons that may not have as much experience with shoulder arthroplasty and/or the PSI technology. Conversely, it could be postulated that greater improvements in accuracy may be seen with the studied PSI technology, when compared to no 3D planning or PSI, with less experienced surgeons. There could also be differences between the PSI technologies when used by less experienced surgeons, either across all cases or based upon the severity of pathology. When the surgeon is part of the method, the effectiveness of the technology is equally dependent upon the surgeon using the technology. A broader study using different surgeons is required to test the effectiveness of this technology. Comparing the results of this study with published results in the literature, 3D CT imaging and implant templating with use of PSI results in more accurate placement of the glenoid implant when compared to 2D CT imaging without templating and use of standard instrumentation. In previous studies, this was most evident in patients with more severe bone deformity. We believe that 3D CT planning and templating provides the most value in defining the glenoid pathology, as well as in the selection of the optimal implant and its placement. However, it should be the judgment of the surgeon, based upon their experience, to select the instrumentation to best achieve the desired result

Assessing glenoid version is important for a successful total shoulder arthroplasty. Glenoid version is defined as the orientation of the glenoid cavity in relation to a plane perpendicular to the scapula body. Glenoid revision averages between 1 to 2 degrees of retroversion and varies between race and sex. In general glenoid retroversion is overestimated by 6.5 degrees on plain radiographs. Furthermore standard axial 2D CT is aligned to the patient's body and not aligned to the scapula. Therefore 3D reconstructions generated from standard CT allows for analysis of the scapula as a free body and correct version measurements can be made unaffected by positioning. If you add a computer modeling coordinate system in which implants can be added, then computer simulation surgery can be performed. This is important because implanting a glenoid component in excessive retroversion leads to increased stress at the glenoid component and cement mantle and decreased contact with the humeral component. Also excessive reaming of the glenoid surface to neutral retroversion can lead to excessive bone loss and penetration of the glenoid vault by either the pegs or the keel of the glenoid component

Background. Humeral version is the twist angle of the humeral head relative to the distal humerus. Pre-operatively, it is most commonly measured referencing the transepicondylar axis, although various techniques are described in literature (Matsumura et al. 2014, Edelson 1999, Boileau et al., 2008). Accurate estimation of the version angle is important for humeral head osteotomy in preparation for shoulder arthroplasty, as deviations from native version can result in prosthesis malalignment. Most humeral head osteotomy guides instruct the surgeon to reference the ulnar axis with the elbow flexed at 90°. Average version values have been reported at 17.6° relative to the transepicondylar axis and 28.8° relative to the ulnar axis (Hernigou, Duparc, and Hernigou 2014), although it is highly variable and has been reported to range from 10° to 55° (Pearl and Volk 1999). These studies used 2D CT images; however, 2D has been shown to be unreliable for many glenohumeral measurements (Terrier 2015, Jacxsens 2015, Budge 2011). Three-dimensional (3D) modeling is now widely available and may improve the accuracy of version measurements. This study evaluated the effects of sex and measurement system on 3D version measurements made using the transepicondylar and ulnar axis methods, and additionally a flexion-extension axis commonly used in biomechanics. Methods. Computed tomography (CT) scans of 51 cadaveric shoulders (26 male, 25 female; 32 left) were converted to 3D models using medical imaging software. The ulna was reduced to 90° flexion to replicate the arm position during intra-operative version measurement. Geometry was extracted to determine landmarks and co-ordinate systems for the humeral long axis, epicondylar axis, flexion-extension axis (centered through the capitellum and trochlear groove), and ulnar long axis. An anatomic humeral head cut plane was placed at the head-neck junction of all shoulders by a fellowship trained shoulder surgeon. Retroversion was measured with custom Matlab code that analysed the humeral head cut plane relative to a reference system based on the long axis of the humerus and each elbow axis. Effects of measurement systems were analyzed using separate 1-way RM ANOVAs for males and females. Sex differences were analyzed using unpaired t-tests for each measurement system. Results. Changing the measurement reference significantly affected version (p<0.001). The ulnar axis method consistently resulted in higher measured version than either flexion-extension axis (males 9±1°, females 14±1°, p<0.001) or epicondylar axis (males 8±1°, females 12±1°, p<0.001). See Figure 1. Version in males (38±11°) was 7° greater than females (31±12°) when referencing the flexion-extension axis (p=0.048). Conclusion. Different measurement systems produce different values of version. This is important for humeral osteotomies; if version is assessed using the epicondyles pre-operatively and subsequently by the ulna intra-operatively, then the osteotomy will be approximately 10° over-retroverted. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aims

This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?

Aims

The aim of the study was to apply 3D measurements for fracture displacement in minimally to moderately displaced acetabular fractures treated nonoperatively, and to evaluate whether this measurement can be used to estimate the likelihood of conversion to total hip arthroplasty (THA) at follow-up.

Background. Dislocation is a common complication after proximal and total femur prosthesis reconstruction for primary bone sarcoma patients. Expandable prosthesis in children puts an additional challenge due to the lengthening process. Hip stability is impaired due to multiple factors: Resection of the hip stabilizers as part of the sarcoma resection: forces acts on the hip during the lengthening; and mismatch of native growing acetabulum to the metal femoral head. Surgical solutions described in literature are various with reported low rates of success. Objective. Assess a novel 3D surgical planning technology by use of 3D models (computerized and physical), 3D planning, and Patient Specific Instruments (PSI) in supporting correction of young children suffering from hip instability after expandable prosthesis reconstruction following proximal femur resection. This innovative technology creates a new dimension of visualization and customization, and could improve understanding of this complex problem and facilitate the surgical decision making and procedure. Method. Two children, both patients with Ewing Sarcoma of the left proximal femur stage-IIB, ages 3/5 years at diagnosis, were treated with conventional chemotherapy followed by proximal femur resection. Both were reconstructed with expandable prosthesis (one at resection and other 4 years after resection). Hip migration developed gradually during lengthening process in the 24m follow up period. 3D software (Mimics, Materialise, Belgium) were used to make computerized 3D models of patients' pelvises. These were used to 3D print 1:1 physical models. Custom 3D planning software (MSk Lab, Imperial College London) allowed surgeons visualizing the anatomical status and assess of problem severity. Thereafter, osteotomies planes and the desired position of acetabular roof after reduction of hip joint were planned by the surgeons. These plans were used to generate 3D printed PSIs to guide the osteotomies during shelf and triple osteotomy surgeries. Accuracy of planning and PSIs were verified with fluoroscopy and post-op X-rays, by comparing cutting planes and post-op position of the acetabulum. Results. Surgeons reported excellent experience with the 3D models (computerized and physical). It helped them in the decision process with an improved understanding of the relationship between prosthesis head and acetabulum, a clear view of the osteophytes and bone formation surrounding the pseudoacetabulum, and osteophytes inside the native acetabulum. These osteophytes were not immediately visible on 2D CT imaging slices. Surgeons reported a good fit and PSIs' simplicity of use. The hip stability was satisfactory during surgery and in the immediate post-op period. X-ray showed a good and centered position of the hip and good levels of the osteotomies. Conclusions. 3D surgical planning and 3D printing was found to be very effective in assisting surgeons facing complex problems. In these particular cases neither CT nor MRI were able to visualize all bony formation and entrapment of prosthesis in the pseudoacetabulum. 3D visualisation can be very helpful for surgical treatment decisions, and by planning and executing surgery with the guidance of PSIs, surgeons can improve their surgical results. We believe that 3D technology and its advantages, can improve success rates of hip stability in this unique cohort of patients

Objective. The aim of the study was to evaluate inter observer reliability and intra observer reproducibility between the three column classification using 3D CT reconstruction models and schatzker classification systems using 2D CT models. Materials and methods. Fifty two consecutive patients with tibial plateau fractures were evaluated by two orthopaedic surgeons. All patients were classified into Schatzker and three column classification systems using CTimages. The Images were evaluated in a randomised and blind fashion. Demographics of the patient were blinded to reduce observer bias. The inter observer reliability was measured for both classfications in round one. In round two the process was repeated after two weeks and the intra observer reproducibility was measured using cohen kappa coefficient and level of agreement based on Landis and Koch. Results. The average inter observer reliability for schatzker classification in round one were (k2D=0.661, 95% CI 0.531–0.697) in round two (k2D = 0.673, 95% CI 0.451–0.774). The three column classification average in round one were (k3D=0.851 95% CI 0.705–0.968), in round two (k3D=0.929 95% CI 0.813–1.00). The average intra observer reproducibility for Schatzker classification in round two for the first obsrever were (k2D=0.689 IQR, 0.6–0.846) for observer two (k2D=0.656 IQR 0.2988–1.0). The average intra observer reproducibility for three column for observer one were (k3D=0.693 IQR, 0.484-.859), for observer two (k3D=0.711 IQR, 0.5185–0.8294). 31 % of patients had a posterior column involvement. Conclusion. Statistically significant inter observer values in both rounds were noted with the three column classification making it, statistically an excellent agreement. The intra observer reproducibility for the three column classification improved as compared to the schatzker classification. The three column classification seems to be effective way to characterise and classify fractures of tibial plateau

Aims

This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient’s contralateral healthy shoulder.

Aims

Iliopsoas impingement occurs in 4% to 30% of patients after undergoing total hip arthroplasty (THA). Despite a relatively high incidence, there are few attempts at modelling impingement between the iliopsoas and acetabular component, and no attempts at modelling this in a representative cohort of subjects. The purpose of this study was to develop a novel computational model for quantifying the impingement between the iliopsoas and acetabular component and validate its utility in a case-controlled investigation.

Aims

Recurrent dislocation is both a cause and consequence of glenoid bone loss, and the extent of the bony defect is an indicator guiding operative intervention. Literature suggests that loss greater than 25% requires glenoid reconstruction. Measuring bone loss is controversial; studies use different methods to determine this, with no clear evidence of reproducibility. A systematic review was performed to identify existing CT-based methods of quantifying glenoid bone loss and establish their reliability and reproducibility

Aims

The amount of glenoid bone loss is an important factor in deciding between soft-tissue and bony reconstruction when managing anterior shoulder instability. Accurate and reproducible measurement of glenoid bone loss is therefore vital in evaluation of shoulder instability and recommending specific treatment. The aim of this systematic review is to identify the range methods and measurement techniques employed in clinical studies treating glenoid bone loss.

Aims

Patient-specific instrumentation has been shown to increase a surgeon’s precision and accuracy in placing the glenoid component in shoulder arthroplasty. There is, however, little available information about the use of patient-specific planning (PSP) tools for this operation. It is not known how these tools alter the decision-making patterns of shoulder surgeons. The aim of this study was to investigate whether PSP, when compared with the use of plain radiographs or select static CT images, influences the understanding of glenoid pathology and surgical planning.

Detailed preoperative planning is essential for open reduction and internal fixation of acetabular fractures if a successful outcome is to be achieved. Decisions such as patient positioning, approach, reduction techniques and implant positioning are greatly influenced by fracture pattern and displacement. These fractures are frequently complex and a thorough understanding of their 3-Dimensional (3D) form is necessary for pre-operative decision making. A combination of biplanar x-rays, 2 Dimensional CT scans (Axial, Sagittal and Coronal multi-plane reformats) and, more recently, 3D CT reconstructions are provided routinely. However, the 3D reconstructions are provided to surgeons as static 2D pictures of the 3D model (up to 6 different views), rather than a true 3D representation. In this study we used dynamic 3D models to provide additional information to surgeons. The 3D models were generated on a standard desktop or laptop computer and can be used in the operating theatre (Osirix Dicom viewing software). These true 3D reconstructions allow the surgeon to manipulate the model himself in real time so that the fracture can be viewed at any angle and overlying fragments removed to expose deeper structures. 3 experienced consultant pelvic trauma surgeons reviewed plain radiographs and 2D Pelvic CT scans from 20 acetabular fractures. They were asked to make a preoperative plan with regard to fracture classification and planned surgical approach(s). At separate, time-spaced, sittings they were provided with a 3D Static and 3D Dynamic CT reconstruction in addition. They were blinded to any previous plan and the patients’ details. A comparison was then made with regard to surgical plan and the time taken to make that plan with or without access to dynamic 3D models. The additional information provided by dynamic 3D modelling was found to reduce planning time and, in some cases, change the surgical plan

Aims

Accurate measurement of the glenoid version is important in performing total shoulder arthroplasty (TSA). Our aim was to evaluate the Ellipse method, which involves formally defining the vertical mid-point of the glenoid prior to measuring the glenoid version and comparing it with the ‘classic’ Friedman method.