Biomechanical comparison of a new expandable intramedullary nail and conventional intramedullary nails for femoral osteosynthesis in dogs

Intramedullary nailing of diaphyseal femoral fractures is a commonly used treatment method in dogs because of its biological and biomechanical advantages compared to bone plating. To achieve adequate resistance of the intramedullary nail against torsional and axial compressive forces, additional application of transcortical screws is needed. As these interlocking screws represent a frequent cause of post-operative complications, a new expandable intramedullary nail (EXPN) was developed, which was designed to provide adequate fracture stabilisation without the need for transcortical fixation. The evaluation of the biomechanical properties of the new EXPN with regard to torsional, compressive and bending stability as well as direct comparison to the biomechanical properties of conventional Steinmann (STMN)- and interlocking (ILN) nails was carried out with different biomechanical test arrangements. No significant statistical differences regarding the torsional and bending resistance between the EXPN and ILN group were seen, which indicates that rotatory as well as bending stability of the innovative EXPN is similar to the conventional ILN. Nevertheless, the percentage deviation between the attempted and successfully reached physiological compressive forces was significantly higher (p = 0.045) in the EXPN group compared to the ILN group, which indicates that the compressive stability of the innovative EXPN might be weaker compared to the ILN. In summary, the new EXPN represents an interesting alternative to conventional intramedullary nails. However, in direct comparison to conventional interlocking nails, the EXPN has shown weaknesses in the neutralization of axial compressive forces, which indicates that at least biomechanically the interlocking nail seems advantageous. Further in-vitro and in-vivo investigations are required before clinical use can be recommended. © 2020 Plenert et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Computer-assisted versus non-computer-assisted preoperative planning of corrective osteotomy for extra-articular distal radius malunions: a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Malunion is the most common complication of distal radius fracture. It has previously been demonstrated that there is a correlation between the quality of anatomical correction and overall wrist function. However, surgical correction can be difficult because of the often complex anatomy associated with this condition. Computer assisted surgical planning, combined with patient-specific surgical guides, has the potential to improve pre-operative understanding of patient anatomy as well as intra-operative accuracy. For patients with malunion of the distal radius fracture, this technology could significantly improve clinical outcomes that largely depend on the quality of restoration of normal anatomy. Therefore, the objective of this study is to compare patient outcomes after corrective osteotomy for distal radius malunion with and without preoperative computer-assisted planning and peri-operative patient-specific surgical guides.</p> <p>Methods/Design</p> <p>This study is a multi-center randomized controlled trial of conventional planning versus computer-assisted planning for surgical correction of distal radius malunion. Adult patients with extra-articular malunion of the distal radius will be invited to enroll in our study. After providing informed consent, subjects will be randomized to two groups: one group will receive corrective surgery with conventional preoperative planning, while the other will receive corrective surgery with computer-assisted pre-operative planning and peri-operative patient specific surgical guides. In the computer-assisted planning group, a CT scan of the affected forearm as well as the normal, contralateral forearm will be obtained. The images will be used to construct a 3D anatomical model of the defect and patient-specific surgical guides will be manufactured. Outcome will be measured by DASH and PRWE scores, grip strength, radiographic measurements, and patient satisfaction at 3, 6, and 12 months postoperatively.</p> <p>Discussion</p> <p>Computer-assisted surgical planning, combined with patient-specific surgical guides, is a powerful new technology that has the potential to improve the accuracy and consistency of orthopaedic surgery. To date, the role of this technology in upper extremity surgery has not been adequately investigated, and it is unclear whether its use provides any significant clinical benefit over traditional preoperative imaging protocols. Our study will represent the first randomized controlled trial investigating the use of computer assisted surgery in corrective osteotomy for distal radius malunions.</p> <p>Trial registration</p> <p>NCT01193010</p

Three-dimensional virtual planning of corrective osteotomies of distal radius malunions: a systematic review and meta-analysis

The purpose of this study was to summarize and evaluate results of three-dimensional (3D-) planned corrective osteotomies of malunited distal radius fractures. 3D-planning techniques provide the possibility to address 3D-deformity that conventional planning methods might not address. We systematically searched PubMed, EMBASE and the Cochrane library for studies that performed a 3D-planned corrective osteotomy on patients with a malunited distal radius fracture. Fifteen studies with a total of 68 patients were included in the analysis. In 96% of cases, the preoperatively present palmar tilt, radial inclination and ulnar variance showed statistically significant improvement postoperatively with restoration to within 5° or 2 mm of their normal values. Mean flexion–extension, pro-supination and grip strength showed statistically significant improvement (p < 0.05). Complications were reported in 11 out of 68 patients (16%). With the current advances in 3D printing technology, 3D-planned corrective osteotomies seem a promising technique in the treatment of complex distal radius malunions. Level of evidence IV Systematic review of case series, Level IV

Radius-ulna shaft fracture with distal radioulnar joint instability in a case of ipsilateral malunited colles fracture: a case report

Malunion of the distal end of radius is a known consequence of the conservative management. The functional impairment depends on the severity of the deformity and it can be associated with distal radioulnar joint (DRUJ) instability. Subsequent radius ulna fracture in an elderly osteoporotic patient is a challenging task to manage. A 60 year old female patient came with radius ulna shaft fracture with DRUJ instability with ipsilateral malunited distal radius fracture. We managed with open reduction and internal fixation using 3.5 mm locking compression plate (LCP) with ulnar shortening and K wires for DRUJ. At one year, follow-up, patient is having good clinical and radiological outcome without any complications. Radius ulna shaft fracture in cases of malunited colles fracture with positive ulnar variance with DRUJ instability can be managed well with open reduction and internal fixation of radius-ulna shaft which provides stable fixation, ulnar shortening at the fracture site to maintain the neutral/negative ulnar variance and DRUJ fixation using K wires. Use of multiple vicryl sutures to tie the plate to the bone gives additional stability in osteoporotic bones till the fracture unites and prevents implant failure. Combination of the above mentioned procedures helps in getting good functional outcome in elderly osteoporotic patients

Innovative mathematical and numerical models for studying the deformation of shells during industrial forming processes with the Finite Element Method

The doctoral thesis "Innovative mathematical and numerical models for studying the deformation of shells during industrial forming processes with the Finite Element Method" aims to contribute to the development of finite element methods for the analysis of stamping processes, a problematic area with a clear industrial application. To achieve the proposed objectives, the first part of this thesis covers the solid-shell elements. This type of element is attractive for the simulation of forming processes, since any type of three-dimensional constitutive law can be formulated without the need to consider any additional conjecture. Additionally, the contact of both sides can be easily treated. This work first presents the development of a triangular prismatic solid-sheet element, for the analysis of thick and thin sheets with capacity for large deformations. This element is in total Lagrangian formulation, and uses neighboring elements to compute a field of quadratic displacements. In the original formulation, a modified right Cauchy tensor was obtained; however, in this work, the formulation is extended obtaining a modified strain gradient, which allows the concepts of push-forward and pull-back to be used. These concepts provide a mathematically consistent method for the definition of temporary derivatives of tensors and, therefore, can be used, for example, to work with elasto-plasticity. This work continues with the development of the contact formulation used, a methodology found in the bibliography on computational contact mechanics for implicit simulations. This formulation consists of an exact integration of the contact interface using mortar methods, which allows obtaining the most consistent integration possible between the integration domains, as well as the most exact possible solution. The most notable contribution of this work is the consideration of dual augmented Lagrange multipliers as an optimization method. To solve the system of equations, a semi-smooth Newton method is considered, which consists of an active set strategy, also extensible in the case of friction problems. The formulation is functional for both frictionless and friction problems, which is essential for simulating stamping processes. This frictional formulation is framed in traditional friction models, such as Coulomb friction, but the development presented can be extended to any type of friction model. The remaining necessary component for the simulation of industrial processes are the constitutive models. In this work, this is materialized in the formulation of plasticity considered. These constitutive models will be considered plasticity models for large deformations, with an arbitrary combination of creep surfaces and plastic potentials: the so-called non-associative models. To calculate the tangent tensor corresponding to these general laws, numerical implementations based on perturbation methods have been considered. Another fundamental contribution of this work is the development of techniques for adaptive remeshing, of which different approaches will be presented. On the one hand, metric-based techniques, including the level-set and Hessian approaches. These techniques are general-purpose and can be considered in both structural problems and fluid mechanics problems. On the other hand, the SPR error estimation method, more conventional than the previous ones, is presented. In this area, the contribution of this work consists in the estimation of error using the Hessian and SPR techniques for the application to numerical contact problems.La tesis doctoral "Modelos matemáticos y numéricos innovadores para el estudio de la deformación de láminas durante los procesos de conformado industrial por el Método de los Elementos Finitos" pretende contribuir al desarrollo de métodos de elementos finitos para el análisis de procesos de estampado, un área problemática con una clara aplicación industrial. De hecho, este tipo de problemas multidisciplinares requieren el conocimiento de múltiples disciplinas, como la mecánica de medios continuos, la plasticidad, la termodinámica y los problemas de contacto, entre otros. Para alcanzar los objetivos propuestos, la primera parte de esta tesis abarca los elementos de sólido lámina. Este tipo de elemento resulta atractivo para la simulación de procesos de conformado, dado que cualquier tipo de ley constitutiva tridimensional puede ser formulada sin necesidad de considerar ninguna conjetura adicional. Además, este tipo de elementos permite realizar una descripción tridimensional del cuerpo deformable, por tanto, el contacto de ambas caras puede ser tratado fácilmente. Este trabajo presenta en primer lugar el desarrollo de un elemento de sólido-lámina prismático triangular, para el análisis de láminas gruesas y delgadas con capacidad para grandes deformaciones. Este elemento figura en formulación Lagrangiana total, y emplea los elementos vecinos para poder computar un campo de desplazamientos cuadráticos. En la formulación original, se obtenía un tensor de Cauchy derecho modificado (¯C); sin embargo, en este trabajo, la formulación se extiende obteniendo un gradiente de deformación modificado (¯F), que permite emplear los conceptos de push-forward y pull-back. Dichos conceptos proveen de un método matemáticamente consistente para la definición de derivadas temporales de tensores y, por tanto, puede ser usado, por ejemplo, para trabajar con elasto-plasticidad. El elemento se basa en tres modificaciones: (a) una aproximación clásica de deformaciones transversales de corte mixtas impuestas; (b) una aproximación de deformaciones impuestas para las Componentes en el plano tangente de la lámina; y (c) una aproximación de deformaciones impuestas mejoradas en la dirección normal a través del espesor, mediante la consideración de un grado de libertad adicional. Los objetivos son poder utilizar el elemento para la simulación de láminas sin bloquear por cortante, mejorar el comportamiento membranal del elemento en el plano tangente, eliminar el bloqueo por efecto Poisson y poder tratar materiales elasto-plásticos con un flujo plástico incompresible, así como materiales elásticos cuasi-incompresibles o materiales con flujo plástico isocórico. El elemento considera un único punto de Gauss en el plano, mientras que permite considerar un número cualquiera de puntos de integración en su eje, con el objetivo de poder considerar problemas con una significativa no linealidad en cuanto a plasticidad. Este trabajo continúa con el desarrollo de la formulación de contacto empleada, una metodología que se encuentra en la bibliografía sobre la mecánica de contacto computacional para simulaciones implícitas. Dicha formulación consiste en una integración exacta de la interfaz de contacto mediante métodos de mortero, lo que permite obtener la integración más consistente posible entre los dominios de integración, así como la solución más exacta posible. La implementación también considera varios algoritmos de optimización, como la optimización mediante penalización. La contribución más notable de este trabajo es la consideración de multiplicadores de Lagrange aumentados duales como método de optimización. Estos permiten condensar estáticamente el sistema de ecuaciones, lo que permite eliminar los multiplicadores de Lagrange de la resolución y, por lo tanto, permite la consideración de solvers iterativos. Además, la formulación ha sido adecuadamente linealizada, asegurando la convergencia cuadrática del problema. Para resolver el sistema de ecuaciones, se considera un método de Newton semi-smooth, que consiste en una estrategia de set activo, extensible también en el caso de problemas friccionales. La formulación es funcional tanto para problemas sin fricción como para problemas friccionales, lo que es esencial para la simulación de procesos de estampado. Esta formulación friccional se enmarca en los modelos de fricción tradicionales, como la fricción de Coulomb, pero el desarrollo presentado puede extenderse a cualquier tipo de modelo de fricción. Esta formulación de contacto es totalmente compatible con el elemento sólido-lámina introducido en este trabajo. El componente necesario restante para la simulación de procesos industriales son los modelos constitutivos. En este trabajo, esto se ve materializado en la formulación de plasticidad considerada. Estos modelos constitutivos se considerarán modelos de plasticidad para grandes deformaciones, con una combinación arbitraria de superficies de fluencia y potenciales plásticos: los llamados modelos no asociados. Para calcular el tensor tangente correspondiente a estas leyes generales, se han considerado implementaciones numéricas basadas en métodos de perturbación. Otra contribución fundamental de este trabajo es el desarrollo de técnicas para el remallado adaptativo, de las que se presentarán distintos enfoques. Por un lado, las técnicas basadas en métricas, incluyendo los enfoques level-set y Hessiano. Estas técnicas son de propósito general y pueden considerarse tanto en la aplicación de problemas estructurales como en problemas de mecánica de fluidos. Por otro lado, se presenta el método de estimación de errores SPR, más convencional que los anteriores. En este ámbito, la contribución de este trabajo consiste en la estimación de error mediante las técnicas de Hessiano y SPR para la aplicación a problemas de contacto numérico. Con los desarrollos previamente introducidos, estaremos en disposición de introducir los casos de aplicación centrados en el contexto de procesos de estampado. Es relevante destacar que estos ejemplos son comparados con las soluciones de referencia disponibles en la bibliografía como forma de validar los desarrollos presentados hasta este punto. El presente documento está organizado de la siguiente manera. El primer capítulo establece los objetivos y revisa la bibliografía acerca de los temas clave de este trabajo. El segundo capítulo hace una introducción de la mecánica de medios continuos y los conceptos relativos al Método de los Elementos Finitos (MEF), necesarios en los desarrollos que se presentarán en los capítulos siguientes. El tercer capítulo aborda la formulación del elemento sólido-lámina, así como del elemento de lámina sin grados de libertad de rotación que inspira el sólido-lámina desarrollado. Esta parte muestra varios ejemplos académicos que son comúnmente empleados en la bibliografía como problemas de referencia de láminas. El cuarto capítulo presenta la formulación desarrollada para la resolución de problemas de contacto numérico, consistente en una formulación implícita de integración exacta mediante métodos mortero y multiplicadores de Lagrange aumentados duales. Este capítulo incluye, asimismo, varios ejemplos comúnmente encontrados en la bibliografía, que generalmente son considerados para su validación. El quinto capítulo presenta la formulación de plasticidad empleada, incluyendo algunos detalles técnicos desde el punto de vista de la implementación, así como varios ejemplos de validación. El sexto capítulo muestra los algoritmos de remallado adaptativo desarrollados en el contexto de este trabajo, y presenta varios ejemplos, que incluyen no solo casos estructurales, sino también de mecánica de fluidos. El séptimo capítulo encapsula algunos casos de validación y aplicación para procesos de estampado. El capítulo final comprende las conclusiones, así como los trabajos que podrían continuar el presente estudio.Postprint (published version

Development and evaluation of image-guided neuroendoscopy, with investigation of post-imaging brain distortion and accuracy of frameless stereotaxy

Neuroendoscopy enables a surgeon to operate deep within the brain whilst limiting morbidity through a minimally invasive approach. Technical advances in illumination, instrumentation and camera design, along with evidence for improved clinical outcome, have increased the indications for this technique and have ensured widespread popularity. However, broader application of neuroendoscopy is restricted by the necessity for direct vision of targets and by spatial disorientation. The aim of this investigation was to overcome these limitations by combining neuronavigation with neuroendoscopy to develop Image-Guided Neuroendoscopy (IGN). The strategy adopted for this was firstly to select, assess and validate a neuronavigation system, secondly to develop methods of endoscope tracking and frameless stereotactic implantation. Thirdly, to assess the impact of post-imaging brain distortion upon neuronavigation, fourthly to correct distortion of the endoscope image and finally to assess the use of graphics overlay in IGN. Laboratory phantom accuracy assessments revealed a mean point localisation error for the navigation system pointers of0.8mm (SD 0.4mm) with CT imaging, for the tracked endoscope of 1.5mm (SD 0.8mm) and for frameless stereotaxy of 1.3mm (SD 0.6mm). An in vivo study revealed a mean Euclidean error of 4.8mm (SD 2.0mm) for frame less stereotactic biopsy. The navigation system was evaluated through a clinical series of 100 cases, the frameless stereotactic technique was employed in 21 brain biopsy procedures and IGN evaluated in 5 procedures. The magnitude of post-imaging brain distortion was determined and correlations discovered with pre-operative image characteristics. The conclusions of this thesis are that IGN can be accomplished with acceptable accuracy, including frameless stereotactic implantation, and that the impact of postimaging brain distortion will not negate the value of IGN in most cases. Thus, the method developed for IGN has overcome both major constraints of neuroendoscopy, enabling endoscopic surgery to pass through and beyond the ventricular wall, to be undertaken safely in cases with distorted anatomy and opening the potential for wider application of these minimally invasive techniques