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A model for clubfoot based on micro‐CT data
Abstract
The pathological anatomy of idiopathic clubfoot has been investigated for more than 180 years using anatomy, computed tomography (CT), histology and microscopy. Seven idiopathic clubfeet and two normal feet of aborted fetuses were dissected in the present study, with special emphasis on the shape of the cartilage and bones. A three-dimensional (3D) micro-CT system, which generates a series of X-ray attenuation measurements, was used to produce computed reconstructed 3D data sets of each of the separated bones. Based on the micro-CT data scans a high-definition 3D colour printing system was used to make a four times enlarged clubfoot model, precisely presenting all the bony malformations. This model reflects the complexity of the anatomy of this disease and is designed to be used in the workshops of orthopaedic surgeons and physiotherapists, for training in new surgical and manipulation techniques.
... The previous literature indicates that CT and MRI are important in assessing clubfoot severity, which will be discussed in this section. However, few studies report the use of MRI (Windisch et al., 2007). In terms of assessing the anteroposterior talocalcaneal angle (Kite"s angle) in treated clubfoot (48 clubfeet and 28 normal feet), found that there is a statistical difference of about 15º (mean) between the radiographic and CT measurements in 36 clubfeet (p < 0.0001). ...
... One of the previous study assessed the talocalcaneal angle in the sagittal plane, talar head and neck-axis-internal rotation, calcaneal-axis-internal rotation, transverse talar neck and head, posterior side calcaneus external rotation, and calcaneus angle (Pekindi et al., 2001). On the other hand, a few studies have used CT scanning to assess the changes in the shape and size of the tarsal bones in the clubfoot, such as the subtalar, talonavicular and calcaneocuboid joints, and the torsion angle of the ankle mortice, declination angle of the neck of the talus (Farsetti et al., 2009), subtalar, talonavicular ,and calcaneocuboid angle , to develop a 3D model to better understand the complexities of the clubfoot (Windisch et al., 2007), and understanding of deformation of the talus and calcaneus (Epeldegui, 2012). The complexity of the anatomical structure and shape of the clubfoot means that it is difficult to describe them objectively. ...
Clubfoot is one of the common pediatric three dimensional foot deformities with incidence of one in 1000 live births. It may present with ankle equinus, hind foot varus, forefoot adductus and cavus deformities. Untreated clubfoot will induce negative impact on daily and social life activities of the children.
For the last decade, conservative methods are more often used to correct the clubfoot than the surgical methods. Many publications reported that Ponseti method is considered as safe and effective conserva-tive method with higher success rate. However, the clubfoot relapses that mainly caused by foot abduction brace, which is one of the components of Ponseti method are very common and it ranges from 10-30 %. Therefore, it is essential to first understand the different types of club foot and then classify them, in order to provide accurate intervention rather than using only one method for all types and degrees of club foot problems.
Development of biomodel of human body parts would be useful to design intervention for club foot as it has been done in several medical field. Few studies have developed accurate 3D clubfoot model. This study used Kinect 3D scanner and rapid prototyping (RP) machine to develop the clubfoot model. A two year child with unilateral clubfoot was recruited from orthopedic hospital in India. Kinect 3D scanner was used to collect the 3D depth image and the data was processed with Artec software to get the 3D clubfoot data. Then, the 3D clubfoot model was used to create a 3D physical model using RP machine. This research is still at the initial stage and more research is required to better understand clubfoot. In conclusion, this model would be low cost and helpful to evaluate and design a clubfoot intervention.
... The previous literature indicates that CT and MRI are important in assessing clubfoot severity, which will be discussed in this section. However, few studies report the use of MRI (Windisch et al., 2007). In terms of assessing the anteroposterior talocalcaneal angle (Kite"s angle) in treated clubfoot (48 clubfeet and 28 normal feet), found that there is a statistical difference of about 15º (mean) between the radiographic and CT measurements in 36 clubfeet (p < 0.0001). ...
... One of the previous study assessed the talocalcaneal angle in the sagittal plane, talar head and neck-axis-internal rotation, calcaneal-axis-internal rotation, transverse talar neck and head, posterior side calcaneus external rotation, and calcaneus angle (Pekindi et al., 2001). On the other hand, a few studies have used CT scanning to assess the changes in the shape and size of the tarsal bones in the clubfoot, such as the subtalar, talonavicular and calcaneocuboid joints, and the torsion angle of the ankle mortice, declination angle of the neck of the talus (Farsetti et al., 2009), subtalar, talonavicular ,and calcaneocuboid angle , to develop a 3D model to better understand the complexities of the clubfoot (Windisch et al., 2007), and understanding of deformation of the talus and calcaneus (Epeldegui, 2012). The complexity of the anatomical structure and shape of the clubfoot means that it is difficult to describe them objectively. ...
... Models, patients and their relatives It can be used as a tool in obtaining the informed consent form for the surgery by providing ease of understanding the surgical procedures for the patient and has positive effects on patient satisfaction. In addition, these models can be stored and model libraries for educational purposes can be created in the future (Windisch et al, 2007). ...
Technology has had an impact on all areas of life, and dentistry has slowly but surely embraced technology. Three-dimensional (3D) imaging is now one of the most widely used dental technologies. In addition, digital cameras, scanning and 3D printing, also known as rapid prototyping, which is an additive manufacturing process in which 3D objects are produced by incrementally depositing a material layer by layer without any reduction of the material, are the most popular technologies used in clinical practice. These improvements can increase the accuracy and efficiency of dental procedures, while reducing the time and cost associated with traditional methods (Vanderberghe, 2020).
Digital dentistry has become an accurate and widely used technique with the introduction of low-dose 3D cone beam computed tomography (CBCT), which has facilitated diagnosis and 3D virtual restoration design. In this chapter, the main features of advances in digital dental technologies will be discussed in light of current dental literature.
3D Imaging
Cone beam computed tomography (CBCT) is a 3D image of the dentomaxillofacial region that can be obtained with a shorter acquisition scan time, at a lower cost and with a lower dose than a medical CT scan. Since its introduction in the late 1990s, CBCT has become popular for imaging in dentistry because of its advantages over other conventional modalities, such as better visualisation of hard tissues without distortion or overlap of structures and high precision in the representation of anatomical structures. By using multiple imaging protocols, the 3D reconstructions provide greater reliability and accuracy for better treatment planning and assessment. CBCT images can be used to display multiplanar 3D visualisation using specific software. This may be available on a computer directly connected to the CBCT or may require a special key to activate. CBCT images are analysed by exporting the data using a standard DICOM (Digital Imaging and Communication in Medicine) file format. Thus, CBCT and associated software made it possible to assess all three dimensions in clinical practice (Asymal et al, 2022; Karslıoglu&Gülsahi, 2022).
... 15,16 cerrahi eğitim ve Simülasyon Üç boyutlu yazıcılar ile elde edilen anatomik modeller aynı zamanda eğitim için kullanılabilir olup uzman hekimler arasında bilgi alışverişi amacı ile paylaşılabilir. 17 Modeller karmaşık anatominin değerlendirilmesine izin vermenin yanı sıra yeni manipülasyon ve cerrahi tekniklerin denenmesine de olanak sağlar. 18 Modeller, hastalar ve yakınları için cerrahi işlemleri anlama kolaylığı sağlayarak ameliyat için bilgilendirilmiş onam formunu almada bir araç olarak kullanılabilir ve hasta memnuniyeti için olumlu etkilere sahiptir. ...
G ünümüzde gelişen teknoloji ile birlikte üç boyutlu yazılım ve baskı teknoloji-leri birçok alanda uygulandığı gibi diş hekimliğinin cerrahi alanında da kulla-nılmaktadır. Bilgisayarlı tomografi (BT), manyetik rezonans görüntüleme (MRG) gibi 3 boyutlu ileri görüntüleme tekniklerinin yanı sıra, özellikle, diş hekimliği branşının tüm alanlarında kullanılabilen konik ışınlı bilgisayarlı tomografinin (KIBT) üç boyutlu yazıcı teknolojisinin gelişiminin hızlanmasına olanak vermiştir. Bu teknoloji, daha üstün tanı ve tedavi planlamasının yanı sıra cerrahi operasyona rehberlik sağlaya-rak cerrahi işlemler sırası ve sonrasında gelişebilecek komplikasyon risklerini azalt-maktadır. Diş hekimliği maksillofasiyal cerrahi alanınında üç boyutlu yazıcı teknolojisinin kullanımından yararlanılan uygulamalar arasında zor veya estetiğin ön planda olduğu bölgelere dental implant uygulamaları, sinüs lifting ve ortoganik cerrahi gibi yer almaktadır. 1,2 ÜÇ BOYuTlu MODelleMe SÜRecİ Üç boyutlu yazıcılar ile oluşturulan tıbbi veya biyo-modeller, BT, KIBT veya MRG gibi üç boyutlu ileri görüntüleme teknikleri yardımıyla, istenilen anatomik yapının yüksek ka-33 Üç Boyutlu Yazıcıların Cerrahi Alanındaki Kullanımı Application of Three-Dimensional Printing in Dentomaxillofacial Surgery ÖZET Üç boyutlu yazıcılar ilerleyen tıbbi teknoloji kullanımıyla birlikte diş hekimliğinin farklı alanla-rında hızla yaygınlaşmaktadır. Konik ışınlı bilgisayarlı tomografi (KIBT) gibi ileri görüntüleme yön-temlerinin diş hekimliğinde kullanımı üç boyutlu yazıcı teknolojisinin gelişiminin hızlanmasına olanak sağlamıştır. Bu teknoloji, diş hekimliğinde uygulanan cerrahi operasyonların tüm aşamalarında fayda sağlayacak kullanım alanlarına sahiptir. Üç boyutlu yazıcıların dentomaksillofasiyal cerrahide kulla-nımı; anatomik modellerin elde edilmesi, cerrahi operasyon enstrümanları ve implant-protezlerinin üre-timi olmak üzere üç ana başlık altında değerlendirilebilir. Bu makalenin amacı üç boyutlu yazıcıların dentomaksillofasiyel cerrahideki kullanımının farklı aşamalarda ve çeşitli amaçlar için incelenmesidir. Anah tar Ke li me ler: Üç boyutlu yazıcılar; üç boyutlu görüntüleme; maksillofasiyal cerrahi; ortognatik cerrahi ABS TRACT Three-dimensional printers have expeditiously become popular in several branches of dentistry with the use of advancing medical technology. The application of advanced imaging methods such as cone-beam computed tomography (CBCT) in dentistry has accelerated the development of three-dimensional printer technology. This technology has areas of usage that will benefit all stages of surgical operations in dentistry. The application of three-dimensional printers in dentomaxillofacial surgery is grouped under three main topic: anatomic models, surgical instruments and implant-prostheses production. The aim of this article is to review the application of three-dimensional printers in the dentomax-illofacial surgery at several stages and for various purposes.
... In literature review, there have been efforts to quantify clubfoot with 3D data. 2,3,4 However, to the best of our knowledge, there has not been a method developed to scan infants without the use of sedation. ...
... Creation of anatomical models to serve as educational aids can now be achieved, thus enhancing training and education of healthcare providers. For example, in the treatment of clubfeet, it has been used to create models which are used to train healthcare providers in manipulation techniques as well as providing a better appreciation of pathologic anatomy [17]. ...
The emergence of 3D printing technology is rapidly changing the face of healthcare. Its impact in pediatric orthopedics has been profound. Innovations such as the creation of precise anatomical models for surgical planning and the production of patient-specific instrumentation and implants are just a few of the ways 3D printing is being utilized in pediatric orthopedics. This chapter reviews the processes involved in medical 3D printing, from magnetic resonance imaging and computerized tomography scans to creation of the final models. It will also outline the current applications of 3D printing in pediatric orthopedics. Finally, the chapter will discuss potential future applications of 3D printing in orthopedic bioprinting and tissue engineering.Keywords3D printingPediatric orthopedicsStereolithographyRapid prototypingBio-inksBioprintingPatient-specific implantsPatient-specific instrumentationBiomaterials
... In addition, although the 3D printing assisted PSI osteotomy guide has been diffusely applied in several clinical studies, such as the cubitus varus deformity, developmental dysplasia of the hip (DDH), spinal scoliosis, hallux valgus, and other deformities [20,[23][24][25], while its application in the correction of ATE malformation has been rarely reported. Previously, Windisch et al. [26] applied 3D printing technique to fabricate a physical model of ATE malformation with a magnification of 4 times for surgeons to accurately analyze all bone and joint deformities and perform preoperative planning, but this application only played the most basic role of 3D printing technique. Moreover, Gozar et al. [16] and Barker et al. [27] applied computer modeling analysis technique to the correction of TE malformation and obtained the satisfactory short-term outcomes, but still lacked a long-term prognostic comparison with the routine group. ...
Objective:
This current research is aimed at assessing clinical efficacy and prognosis of three-dimensional (3D) printing assisted patient-specific instrument (PSI) osteotomy guide in precise osteotomy of adult talipes equinovarus (ATE).
Methods:
We included a total of 27 patients of ATE malformation (including 12 males and 15 females) from June 2014 to June 2018 in the current research. The patients were divided into the routine group (n = 12) and 3D printing group (n = 15) based on different operative methods. The parameters, including the operative time, intraoperative blood loss, complications, time to obtain bony fusion, functional outcomes based on American Orthopedic Foot and Ankle Society (AOFAS), and International Congenital Clubfoot Study group (ICFSG) scoring systems between the two groups were observed and recorded regularly.
Results:
The 3D printing group exhibits superiorities in shorter operative time, less intraoperative blood loss, higher rate of excellent, and good outcomes presented by ICFSG score at last follow-up (P < 0.001, P < 0.001, P = 0.019) than the routine group. However, there was no significant difference exhibited in the AOFAS score at the last follow-up and total rate of complications between the two groups (P = 0.136, P = 0.291).
Conclusion:
Operation assisted by 3D printing PSI osteotomy guide for correcting the ATE malformation is novel and feasible, which might be an effective method to polish up the precise osteotomy of ATE malformation and enhance the clinical efficacy.
... Una de las primeras citaciones bibliográficas que encontramos de modelos impresos en 3D en pie y tobillo es también una de las primeras publicaciones en el campo de la cirugía ortopédica. Windisch y Salaberger publicaron un artículo en 2007 donde explican cómo obtuvieron diferentes modelos tridimensionales de pies equinovaros para comprender y definir mejor la compleja anatomía y la deformidad de sus pacientes (3) . ...
... 19,20 Other orthopedic applications apart from preoperative planning include teaching and patient counseling. 21,22 Recent advances in fused deposition modeling (FDM), a RP technique has made it a viable technology for application in orthopedic surgery. Use of FDM in the fabrication of skull and mandible with a high level of accuracy has been documented. ...
... Although 3D printing assisted guide plates have been diffusely applied in clinical correction researches of cubitus varus deformity, developmental dysplasia of the hip, spinal scoliosis, hallux valgus and other deformities [17][18][19][20], while the application in ATE malformation correction has been rarely reported. Previously, Windisch et al. [21] applied 3D printing technology to fabricate a physical model of ATE malformation with a magnification of 4 times for surgeons to accurately analyze all bone and joint deformities, and perform preoperative planning, but this application only played the most basic role of 3D printing. Moreover, Gozar et al. [15] and Barker et al. [22] applied computer modeling analysis technology to the correction of TE malformation, and obtained the satisfactory short-term outcomes, but still lacked a long-term prognostic comparison with routine group. ...
Objectives: This current research is aimed to assess clinical efficacy and prognosis of three-dimensional (3D) printing assisted osteotomy guide plate in precise osteotomy of adult talipes equinovarus (ATE).
Materials and Methods: We included a total of 27 patients of ATE malformation (including 12 males and 15 females) from January 2014 to June 2018 in current research. The patients were divided into the routine group (n=12) and 3D printing group (n=15) based on different operative methods. The parameters, including the operative time, intraoperative blood loss, complications, time to obtain bony fusion, functional outcomes based on American Orthopedic Foot and Ankle Society (AOFAS) and International Congenital Clubfoot Study group (ICFSG) scoring systems between the two groups were observed and recorded regularly.
Results: The 3D printing group exhibits superiorities in shorter operative time, less intraoperative blood loss, higher rate of excellent and good outcomes presented by ICFSG score at last follow-up (P< 0.001, P< 0.001, P =0.019) than the routine group. However, there was no significant difference exhibited in AOFAS score at last follow-up and total rate of complications between the two groups (P=0.136, P =0.291).
Conclusions: Operation assisted by 3D printing osteotomy guide plates for correcting the ATE malformation is novel and feasible, which might be an effective method to polish up the precise osteotomy of ATE malformation and enhance the clinical efficacy.
... Staining is only necessary when a researcher is interested in imaging soft tissue. Without staining, micro-CT provides great spatial resolution for high-density structures (e.g., orbit, humerus, femur) even if the structures are not completely ossified yet [20][21][22][23][24][25][26][27][28][29][30][31][32][33]. Staining is performed by immersing the whole fetus or fetal organ in a staining solution. ...
Background:
MRI and CT have been extensively used to study fetal anatomy for research and diagnostic purposes, enabling minimally invasive autopsy and giving insight in human fetal development. Novel (contrast-enhanced) microfocus CT (micro-CT) and ultra-high-field (≥ 7.0 T) MRI (UHF-MRI) techniques now enable micron-level resolution that combats the disadvantages of low-field MRI and conventional CT. Thereby, they might be suitable to study fetal anatomy in high detail and, in time, contribute to the postmortem diagnosis of fetal conditions.
Objectives:
(1) To systematically examine the usability of micro-CT and UHF-MRI to study postmortem human fetal anatomy, and (2) to analyze factors that govern success at each step of the specimen preparation and imaging.
Method:
MEDLINE and EMBASE were systematically searched to identify publications on fetal imaging by micro-CT or UHF-MRI. Scanning protocols were summarized and best practices concerning specimen preparation and imaging were enumerated.
Results:
Thirty-two publications reporting on micro-CT and UHF-MRI were included. The majority of the publications focused on imaging organs separately and seven publications focused on whole body imaging, demonstrating the possibility of visualization of small anatomical structures with a resolution well below 100 μm. When imaging soft tissues by micro-CT, the fetus should be stained by immersion in Lugol's staining solution.
Conclusion:
Micro-CT and UHF-MRI are both excellent imaging techniques to provide detailed images of gross anatomy of human fetuses. The present study offers an overview of the current best practices when using micro-CT and/or UHF-MRI to study fetal anatomy for clinical and research purposes.
Key points:
• Micro-CT and UHF-MRI can both be used to study postmortem human fetal anatomy for clinical and research purposes. • Micro-CT enables high-resolution imaging of fetal specimens in relatively short scanning time. However, tissue staining using a contrast solution is necessary to enable soft-tissue visualization. • UHF-MRI enables high-resolution imaging of fetal specimens, without the necessity of prior staining, but with the drawback of long scanning time.
... Reducing patient death and unforeseen complications from medical error in the operating room has driven the need to develop and provide surgical simulation technologies to medical students and practitioners [2,3]. Many medical fields, such as cardiology [4,5], orthopedics [6][7][8][9][10], radiology [11,12], urology [13][14][15], plastic surgery [16,17], and neurology [18][19][20] have begun adopting 3D printing to fabricate functional, patient-specific anatomical models with customizable geometries, which can be utilized in simulation applications [2]. Initial analog models were limited to rigid plastic replicas with significantly different mechanical and optical properties than those of the modeled organ [21][22][23], decreasing the sense of realism. ...
Medical training simulations that utilize 3D-printed, patient-specific tissue models improve practitioner and patient understanding of individualized procedures and capacitate pre-operative, patient-specific rehearsals. The impact of these novel constructs in medical training and pre-procedure rehearsals has been limited, however, by the lack of effectively embedded sensors that detect the location, direction, and amplitude of strains applied by the practitioner on the simulated structures. The monolithic fabrication of strain sensors embedded into lifelike tissue models with customizable orientation and placement could address this limitation. The demonstration of 3D printing of an ionogel as a stretchable, piezoresistive strain sensor embedded in an elastomer is presented as a proof-of-concept of this integrated fabrication for the first time. The significant hysteresis and drift inherent to solid-phase piezoresistive composites and the dimensional instability of low-hysteresis piezoresistive liquids inspired the adoption of a 3D-printable piezoresistive ionogel composed of reduced graphene oxide and an ionic liquid. The shear-thinning rheology of the ionogel obviates the need to fabricate additional structures that define or contain the geometry of the sensing channel. Sensors are printed on and subsequently encapsulated in polydimethylsiloxane (PDMS), a thermoset elastomer commonly used for analogue tissue models, to demonstrate seamless fabrication. Strain sensors demonstrate geometry- and strain-dependent gauge factors of 0.54-2.41, a high dynamic strain range of 350% that surpasses the failure strain of most dermal and viscus tissue, low hysteresis (<3.5% degree of hysteresis up to 300% strain) and baseline drift, a single-value response, and excellent fatigue stability (5,000 stretching cycles). In addition, we fabricate sensors with stencil-printed silver/PDMS electrodes in place of wires to highlight the potential of seamless integration with printed electrodes. The compositional tunability of ionic liquid/graphene-based composites and the shear-thinning rheology of this class of conductive gels endows an expansive combination of customized sensor geometry and performance that can be tailored to patient-specific, high-fidelity, monolithically fabricated tissue models.
... Clubfoot is a three-dimensional (3D) musculoskeletal foot deformity that affects 150,000-200,000 newborn babies annually around the world 1 . This condition is characterized by four types of foot deformities: midfoot cavus, forefoot adductus, and hindfoot varus and equinus [2][3][4] . ...
OBJECTIVE: Clubfoot is a complex congenital three-dimensional foot deformity, which affects 150,000-200,000 newborn babies annually around the world. A good understanding of the alignment of the two osseous columns and the lower leg of the ankle and foot complex is essential for evaluating the severity of clubfoot. The purposes of this study were to (1) develop an automated three-dimensional (3D) surface model of severe clubfoot based on two-dimensional (2D) slices of computed tomography (CT) images, (2) evaluate the alignment of foot bones relative to the ankle in severe clubfoot, and (3) examine the structural changes in the shape of the clubfoot.
PATIENTS AND METHODS: Two-dimensional CT image was taken from a four-year-old child with a severe clubfoot. Subsequently, an automated and detailed 3D surface model of the severe clubfoot was developed from the 2D images by using MATLAB software programming. Then, the x, y, and z coordinate angles were automatically calculated for each bone in the foot relative to the ankle (lower end of the tibia) to determine the orientations and relationships among the bones.
RESULTS: The relative position or orientation of each bone of the foot to the ankle of the severe clubfoot was objectively measured which was used to determine the orientation of each bone in the foot. Among the x, y, and z axes of the interested tarsal bones, the z axis represents the smallest moment of inertia, and the results showed that the bones in the x axis shifted medially with higher relative angle.
CONCLUSIONS: This 3D objective measurement method for assessing clubfoot can be used to determine and classify the severity of clubfoot, as well as evaluate and monitor the progress of the clubfoot intervention based on the relative position of the tarsal bones. The method can also be used to quantify the relationship between the tarsal bones of the foot and lower end of the tibia. In addition, angular measurements can be used to assess other pathological conditions of the foot such as pes cavus and pes planus.
... Threedimensional (3D) printing is becoming a more mature technology, and its use is becoming more widespread. In the field of orthopedic diagnosis and treatment, 3D printing offers advantages for the accurate preoperative design of a prosthesis, the manufacturing of an individualized prosthesis, and simulating surgery [1][2][3][4][5][6][7][8][9][10][11][12][13]. The results of computed tomography (CT), magnetic resonance imaging (MRI), and some other radiographic techniques provide the basis for fabricating structures via 3D printing. ...
... 19,20 Other orthopedic applications apart from preoperative planning include teaching and patient counseling. 21,22 Recent advances in fused deposition modeling (FDM), a RP technique has made it a viable technology for application in orthopedic surgery. Use of FDM in the fabrication of skull and mandible with a high level of accuracy has been documented. ...
Background
Rapid prototyping (RP) is used widely in dental and faciomaxillary surgery with anecdotal uses in orthopedics. The purview of RP in orthopedics is vast. However, there is no error analysis reported in the literature on bone models generated using office-based RP. This study evaluates the accuracy of fused deposition modeling (FDM) using standard tessellation language (STL) files and errors generated during the fabrication of bone models.
Materials and Methods
Nine dry bones were selected and were computed tomography (CT) scanned. STL files were procured from the CT scans and three-dimensional (3D) models of the bones were printed using our in-house FDM based 3D printer using Acrylonitrile Butadiene Styrene (ABS) filament. Measurements were made on the bone and 3D models according to data collection procedures for forensic skeletal material. Statistical analysis was performed to establish interobserver co-relation for measurements on dry bones and the 3D bone models. Statistical analysis was performed using SPSS version 13.0 software to analyze the collected data.
Results
The inter-observer reliability was established using intra-class coefficient for both the dry bones and the 3D models. The mean of absolute difference is 0.4 that is very minimal. The 3D models are comparable to the dry bones.
Conclusions
STL file dependent FDM using ABS material produces near-anatomical 3D models. The high 3D accuracy hold a promise in the clinical scenario for preoperative planning, mock surgery, and choice of implants and prostheses, especially in complicated acetabular trauma and complex hip surgeries.
... Nowadays, modern methods such as micro-CT, CT, MRI and Doppler ultrasound (Cooke et al. 2008) tend to study the tissue directly with in vivo potential. The results are either used for 3D models, for instance for custom orthosis (Vijayaragavan et al. 2014), clubfoot surgical model (Windisch et al. 2007) or for comparison with foot pressure and gait biomechanical analysis at clubfoot (Herd et al. 2004). This combination of methods was able to reveal some functional abnormalities even at corrected and well-functioned clubfoot (Hee et al. 2001). ...
Idiopathic pes equinovarus (clubfoot) is a congenital deformity of the foot and lower leg defined as a fixation of the foot in plantar flexion, adduction, supination and varus. The deformity does not affect only the foot position, which is usually investigated by radiography, CT, micro-CT, MRI or ultrasound but logically influence the whole gait biomechanics. It is supposed, that clubfoot belongs to a group of fibroproliferative disorders whose origin and multi-hierarchical effect remain unknown. It has been suggested that fibroblasts and growth factors may be involved. To gain a more global view, direct analysis of the protein composition of extracellular matrix, a proteomic approach was used. At present two principle methods are mostly used for the treatment of clubfoot: physiotherapy and the Ponseti method. The determination of the general biological and biomechanical parameters for various regions of the clubfoot can potentially help in the understanding of the mechanisms participating on this serious anomaly and thus contribute to the development of the more efficient therapeutic approach. This review summarizes the present knowledge on the possible pathogenetic mechanisms participating in the development of the clubfoot and their possible relation to the new therapeutic approaches.
... Three-dimensional models of complex abnormalities are, for example, printed for educational purposes and to help surgeons in preoperative planning for challenging surgeries. [6][7][8] Moreover, patient-specific Figure 1. Evolution of cartilage repair and bioprinting of cartilage. ...
Three-dimensional (3D) bioprinting techniques can be used for the fabrication of personalized, regenerative constructs for tissue repair. The current article provides insight into the potential and opportunities of 3D bioprinting for the fabrication of cartilage regenerative constructs. Although 3D printing is already used in the orthopedic clinic, the shift toward 3D bioprinting has not yet occurred. We believe that this shift will provide an important step forward in the field of cartilage regeneration. Three-dimensional bioprinting techniques allow incorporation of cells and biological cues during the manufacturing process, to generate biologically active implants. The outer shape of the construct can be personalized based on clinical images of the patient’s defect. Additionally, by printing with multiple bio-inks, osteochondral or zonally organized constructs can be generated. Relevant mechanical properties can be obtained by hybrid printing with thermoplastic polymers and hydrogels, as well as by the incorporation of electrospun meshes in hydrogels. Finally, bioprinting techniques contribute to the automation of the implant production process, reducing the infection risk. To prompt the shift from nonliving implants toward living 3D bioprinted cartilage constructs in the clinic, some challenges need to be addressed. The bio-inks and required cartilage construct architecture need to be further optimized. The bio-ink and printing process need to meet the sterility requirements for implantation. Finally, standards are essential to ensure a reproducible quality of the 3D printed constructs. Once these challenges are addressed, 3D bioprinted living articular cartilage implants may find their way into daily clinical practice.
... This technique was used by another group who created a four times enlarged clubfoot model based on micro CT data. 16 The group printed each foot bone separately and then glued them together at the joints. As the bones are glued together manually, an issue that might present itself is the loss of their relative positions. ...
... This technique was used by another group who created a four times enlarged clubfoot model based on micro CT data. 16 The group printed each foot bone separately and then glued them together at the joints. As the bones are glued together manually, an issue that might present itself is the loss of their relative positions. ...
Physical models of the human body are important tools in teaching anatomy, training medical professionals, planning complex surgeries, educating patients, and demonstrating medical devices. We present a patient-specific clubfoot model with rigid foot bones suspended independently in a transparent gel matrix that reveals the internal skeletal structure. Compared to cadavers and prosections, our model is a clean and convenient alternative. It offers continuous visual feedback through the transparent skin layer (ideal for training purposes), can be manufactured at demand and reused, and does not require expensive storage and handling facilities. As opposed to other models, which are either purely rigid or flexible, our model is flexible yet with underlying rigid skeletal structure. We believe it has the highest fidelity to human clubfoot in terms of both anatomical structures and material properties. To make this clubfoot model, the knee-to-toe skeleton was first 3D printed using data segmented from a patient's CT data. Then, ballistic gel was melted and cast over the skeleton to create the transparent and flexible skin layer. The flexibility of this clubfoot model permits its recovery to normal foot shape. In addition, the ability of the gel to be repaired with significant recovery of ductility (2.1 ± 0.4 vs. 3.3 ± 0.2, p < 0.05) enables reuse of the model. Ductility of the finished model can be significantly increased by applying an additional elastic coating (4.3 ± 0.2 vs. 5.2 ± 0.2, p < 0.05). This clubfoot model opens up the possibility of making other high-fidelity models with complex anatomies and/or material structures.
... Models can also be used for education and shared understanding across specialties or with patients. Within orthopedics, 3DP has been used to create models of clubfoot four times larger than real life [21]. As well as allowing for assessment of complicated anatomy, the model was used by surgeons, physiotherapists, and patients for shared understanding of the deformity. ...
... 10 For example, medical researchers can use specimen or patient-specific models to improve both communication and comprehension with their colleagues and patients. 11 Although representation on 2D screens has come a long way, there is absolutely no replacement for the visual and sensory experience of holding a real object that is able to be held, rotated, examined and moved around. A model paired with an electronic data representation is even more powerful as it allows researchers to examine the physical object for regions of interest, and to find those areas on a computer model for further quantitative analysis. ...
Three-dimensional printing allows for the production of highly detailed objects through a process known as additive manufacturing. Traditional, mold-injection methods to create models or parts have several limitations, the most important of which is a difficulty in making highly complex products in a timely, cost-effective manner.(1) However, gradual improvements in three-dimensional printing technology have resulted in both high-end and economy instruments that are now available for the facile production of customized models.(2) These printers have the ability to extrude high-resolution objects with enough detail to accurately represent in vivo images generated from a preclinical X-ray CT scanner. With proper data collection, surface rendering, and stereolithographic editing, it is now possible and inexpensive to rapidly produce detailed skeletal and soft tissue structures from X-ray CT data. Even in the early stages of development, the anatomical models produced by three-dimensional printing appeal to both educators and researchers who can utilize the technology to improve visualization proficiency. (3, 4) The real benefits of this method result from the tangible experience a researcher can have with data that cannot be adequately conveyed through a computer screen. The translation of pre-clinical 3D data to a physical object that is an exact copy of the test subject is a powerful tool for visualization and communication, especially for relating imaging research to students, or those in other fields. Here, we provide a detailed method for printing plastic models of bone and organ structures derived from X-ray CT scans utilizing an Albira X-ray CT system in conjunction with PMOD, ImageJ, Meshlab, Netfabb, and ReplicatorG software packages.
... Medical applications have generally been within an academic centre or research environment, as support costs (expertise, software, and equipment) have been large. Applications within clinical practice include preoperative planning/conceptualisation, procedure rehearsal [1–7], and educational tools for teaching [8] and patient communication [9]. ...
Rapid prototyping (RP) is applicable to orthopaedic problems involving three dimensions, particularly fractures, deformities, and reconstruction. In the past, RP has been hampered by cost and difficulties accessing the appropriate expertise. Here we outline the history of rapid prototyping and furthermore a process using open-source software to produce a high fidelity physical model from CT data. This greatly mitigates the expense associated with the technique, allowing surgeons to produce precise models for preoperative planning and procedure rehearsal. We describe the method with an illustrative case.
... Congenital talipes equinovarus (CTEV), classically referred to as 'clubfoot', is a 3D malformation that is immediately recognisable at birth, in which the ankle is in the plantar flexed (equinus) position, the heel is inverted (varus) and the mid foot and fore foot are inverted and adducted (varus). Several recent studies have described the detailed anatomy of both skeletal and soft tissues in clubfoot in human fetuses between the 25th and 37th week of gestation (Fritsch & Eggers, 1999;Gruber et al., 2001;Windisch et al., 2007a,b) and a 3D model for clubfoot has been made using micro-computed tomography to visualize the shape of the individual bones of the foot (Windisch et al., 2007c). The prevalence of CTEV varies around the world from 0.3 to 7 per 1000 live births and it may be bilateral or unilateral (reviewed Miedzybrodzka, 2003;Cardy et al., 2007). ...
Gross similarities between the external appearance of the hind limbs of the peroneal muscle atrophy (pma) mouse mutant and congenital talipes equinovarus (CTEV), a human disorder historically referred to as 'clubfoot', suggested that this mutant could be a useful model. We used micro-magnetic resonance imaging to visualize the detailed anatomy of the hind limb defect in mutant pma mice and performed 3D comparisons between mutant and wild-type hind limbs. We found that the pma foot demonstrates supination (i.e. adduction and inversion of the mid foot and fore foot together with plantar flexion of the ankle and toes) and that the tibiale and distal tarsals display 3D abnormalities in positioning. The size and shape of the tibia, fibula, tarsal and metatarsal bones are similar to the wild-type. Hypoplasia of the muscles in the antero-lateral (peroneal) compartment was also demonstrated. The resemblance of these features to those seen in CTEV suggests that the pma mouse is a possibly useful model for the human condition. To understand how the observed deformities in the pma mouse hind foot arise during embryonic development, we followed the process of foot rotation in both wild-type and pma mutant mice. Rotation of the hind foot in mouse embryos of wild-type strains (CD-1 and C57/Black) occurs from embryonic day 14.5 onwards with rotation in C57/Black taking longer. In embryos from both strains, rotation of the right hind foot more commonly precedes rotation of the left. In pma mutants, the initiation of rotation is often delayed and rotation is slower and does not reach completion. If the usefulness of the pma mutant as a model is confirmed, then these findings on pma mouse embryos, when extrapolated to humans, would support a long-standing hypothesis that CTEV is due to the failure of completion of the normal process of rotation and angulation, historically known as the 'arrested development hypothesis'.
A 5-month-old male domestic shorthair cat was presented with severe bilateral hind-limb deformities that caused the cat to walk on the dorsal aspect of the metatarsals. Computed tomography (CT) images revealed that the calcaneus was externally rotated, and the distal end of the calcaneus was turned medially to the talus in both hind limbs. The cat was diagnosed with twisted leg deformity, a congenital tarsal hyperextension deformity (clubfoot). Based on CT images, closing wedge ostectomy was done at the level of the tarsometatarsal joint with the wider part facing laterally. Partial transection of the common calcaneal tendon was not performed. Nine weeks after surgery, the cat was able to walk and jump, with its paws correctly placed on the ground, despite the limited range of motion in the tarsal joints. Based on radiographs with maximum tarsal flexion, the angle of the partial tarsal arthrodesis limited the range of motion. This is apparently the first case report describing CT images and closing wedge ostectomy in a cat with twisted leg deformity. Key clinical message: This article reports the findings obtained from CT imaging of a cat with twisted leg deformity. The current case was successfully managed by closing wedge ostectomy without partial transection of the common calcaneal tendon.
Introduction
Clubfoot, mainly CTEV, is a complex three-dimensional deformity challenging physicians from ancient times. Among a thousand babies born, one to six suffer from clubfoot deformity; that is, in India alone, around 35,000 need treatment for clubfoot annually. This review summarizes the various practices of clubfoot assessment, noninvasive treatment, and engineering aspects of clubfoot treatment. The shortcomings of assessment methods and challenges with implementation of treatment methods are also presented.
Methods
A narrative review of all related research papers available to authors was carried out.
Results
Various clubfoot assessment methods have been developed to help physicians understand the severity of the problem and predict treatment parameters. The Pirani score and Dimeglio score are used predominantly for the assessment of deformity. However, these methods suffer from implementation-related limitations. Noninvasive methods, namely, Kite's method, functional physiotherapy method, and Ponseti method, are used in practice for treatment. The Ponseti method is the most popular with parents and physicians and is considered the gold standard for the treatment of clubfoot. However, it also suffers from various implementation issues, like treatment cost and lack of experts, particularly in low- and middle-income countries (LMICs). Engineers are using various technologies like computer-aided design (CAD)/computer-aided engineering (CAE) and additive manufacturing for modeling and analysis of clubfoot. Engineers have also attempted to develop corrective and maintenance orthosis for CTEV treatment.
Conclusions
Because newer and newer technologies are becoming accessible for interdisciplinary use, there is a need to apply contemporary technologies, especially to develop a corrective orthosis so that the current challenges of clubfoot assessment and treatment are addressed. The corrective orthosis should be based on Dr Ponseti's insights into clubfoot biomechanics.
Clinical Relevance
There is a need to explore contemporary technologies like data acquisition and CAD/CAE to address CTEV assessment–related issues. A corrective orthosis based on the understanding of the foot biomechanics for treatment can solve the various implementation-related challenges of the Ponseti method, particularly in low-resource settings.
3D printing technology represents an important advancement in medical applications. 3D printed models are recently being used for the production of anatomical and surgical models, surgical guides, functional tissues and organs as well as organ-on-a-chip platforms and custom-made pharmaceutics that allowed the development of new frontiers in medical research and surgical practice. The technology provides advantages to surgeons to perform pre-op planning to analyze the defect areas and malignancies in detail, which facilitates the prediction of the technical difficulties that can be encountered during surgery. 3D printed models are also used to improve the learning experience in medical education. The development of case specific implants for surgery, prosthetics, and orthotics is also possible with 3D printing technology. These products can be produced with personalized size, structure, and features. This chapter will review the potential and current applications of 3D printing technology in shoulder arthroplasty and in the development of patient-specific surgical guides and anatomical models for shoulder surgery.
Clubfoot, or talipes equinovarus, is the most common pediatric orthopedic deformity requiring treatment. Although the deformity may appear to be severe, particularly when first discovered after birth, treatment is successful in the vast majority of cases. This article describes the diagnostics, classification, pathological anatomy and treatment of clubfoot. In addition, the treatment alternatives to the widely used Ponseti method are presented and the counselling for parents of affected children is discussed.
Objectives
Medical three‐dimensional (3D) printing, the fabrication of handheld models from medical images, has the potential to become an integral part of otolaryngology–head and neck surgery (Oto‐HNS) with broad impact across its subspecialties. We review the basic principles of this technology and provide a comprehensive summary of reported clinical applications in the field.
Methods
Standard bibliographic databases (MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and The Cochrane Central Registry for Randomized Trials) were searched from their inception to May 2018 for the terms: “3D printing,” “three‐dimensional printing,” “rapid prototyping,” “additive manufacturing,” “computer‐aided design,” “bioprinting,” and “biofabrication” in various combinations with the terms: “ptolaryngology,” “head and neck surgery,” and “otology.” Additional articles were identified from the references of retrieved articles. Only studies describing clinical applications of 3D printing were included.
Results
Of 5,532 records identified through database searching, 87 articles were included for qualitative synthesis. Widespread implementation of 3D printing in Oto‐HNS is still at its infancy. Nonetheless, it is increasingly being utilized across all subspecialties from preoperative planning to design and fabrication of patient‐specific implants and surgical guides. An emerging application considered highly valuable is its use as a teaching tool for medical education and surgical training.
Conclusions
As technology and training standards evolve and as healthcare moves toward personalized medicine, 3D printing is emerging as a key technology in patient care in Oto‐HNS. Treating physicians and surgeons who wish to stay abreast of these developments will benefit from a fundamental understanding of the principles and applications of this technology. Laryngoscope, 2019
CLUBFOOT- This book has been written as an invited book for Taylor & Francis, a premier Globally reputed publishers. This is a comprehensive book of 50 years, 3 phased, research.Its last chapter should prove to be the future of correction of EXTREME CLUBFOOT Deformities at all ages, even rarest of rare(as reported in Int. orthop. (SICOT) June 2018 issue)' which has been a prevalent neglected area world wide. This book was released on 29th November at Coimbatore IOACON 2018, after a prestigious Diamond Jubilee Oration Award. Author also got Silver & Golden for the earlier 2 phases of this research.
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Dreidimensionale Bildgebung ist aus dem klinischen Alltag der
Zahnmedizin nicht mehr wegzudenken. CT-Untersuchungen an
Kindern sind jedoch sehr selten. Durch eine Kooperation mit
dem pathologisch-anatomischen Museum Wien und der FH Wels
war es mögl i ch, hochauf lösende Mikrofokus -
Computertomographien (μCT) eines Säuglingsschädels mit multiplen
oralen Fehlbildungen zu erstellen und zu analysieren.
Three dimensional (3D) printing can be used to create material models to aid preoperative planning of complex orthopedic procedures as exemplified by this case of total hip arthroplasty failure due to infection with resulting severe acetabular bone stock deficiency. The 3D model allowed for trialing of the acetabular component to determine cup size, position, and screw placement. Most importantly, the model confirmed that there was not a pelvic discontinuity and the revision shell would be sufficient for the reconstruction. Previously, the cost and complexity of utilization of 3D printers were prohibitive. Recent improvements in commercially available 3D printers have made rapid prototype model creation a realistic option, which can facilitate difficult surgery.
In-toeing and out-toeing, or inward and outward rotation of the foot with respect to the direction of walking, respectively, are common reasons for parental concerns and referral for a specialist opinion. A normal range of values can be considered to lie within two standard deviations on either side of the mean of the values for a given population (Jacquemier et al. 2008) (Fig. 21.1).
A paucity of published data is available describing the methods for the integration of 3-dimensional (3D) printing technology and surgical simulation into orthopedic surgery. The cost of this technology has decreased and the ease of use has increased, making routine use of 3D printed models and surgical simulation for difficult orthopedic problems a realistic option. We report the use of 3D printed models and surgical simulation for preoperative planning and patient education in the case of deformity correction in foot and ankle surgery using open source, free software.
Clubfoot is one of the most common congenital abnormalities. Prenatal examination mainly relies on ultrasound. Correct prenatal diagnosis can help the parents understand the deformity, decide whether to continue pregnancy, whereas accurate clinical evaluation of the deformity after birth plays an important role in therapy and prognosis. The etiology, pathology, the prenatal diagnosis and the postnatal evaluation of congenital talipes equinovarus were reviewed in this article.
The clubfoot is a common, classic, paediatric orthopaedic problem. Every orthopaedic surgeon knows what the deformity looks like but most find it more difficult to describe or to define. The etiology is still largely unknown but ideas about treatment have changed considerably over the last few years.
Club foot is a common congenital abnormality, and a complex deformity. In the past twenty years, the deformity has been better classified by considering the different components of deformity. The Pirani scoring system is widely used - and analagous standardised photographic views can be used to document this condition and its progress. Here I describe four views that aid in deformity assessment, correlating to component deformities assessed in the Pirani score.
Advanced applications of materials need sophisticated measurement methods for research, process development and quality control. X-ray Computed Tomography (CT) is a very powerful method for non-destructive testing of materials. A CT-scanner generates a series of X-ray attenuation measurements, which are used to produce computed reconstructed images of an object. In the last years 3D-CT systems with matrix detectors have become more and more popular. In this paper we outline the extended possibilities of 3D Computed Tomography by using a 450 kV-macro focus x-ray source and a 225 kV micro-focus source within one CT system as well as the advantages by applying different CT-methods for the characterisation of one specimen. The possibility of using two different X-ray sources within one CT-device leads to considerable advantages at certain circumstances. If there are different materials in one specimen the application of two different energies can lead to a significant improvement of the contrast. Moreover, if bigger parts are scanned, the 450 kV- source can be used to get an overall image of the specimen and the 225 kV can be used to get a high resolution image of a detail. In the second section we discuss the limits of 3D-CT and apply an advanced CT-mode (region of interest CT) for the characterisation of flat parts and of selected details in large objects. With the ROI- CT-mode "zooming" is possible similar to optical microscopes and a resolution down to 1/10.000 of the part diameter can be reached. This is a much higher resolution as compared to usual 3D-CT.
Die Mikrosystemtechnik ist eine Schlüsseltechnologie für viele Industriezweige geworden. Die Palette von Mikrobauteilen beinhaltet elektronische, mechanische, optische und fluidische Produkte, die aus unterschiedlichsten Kunststoffen, Metallen oder aus Silizium hergestellt werden. An die Methoden für die Qualitätssicherung hinsichtlich der Prüfung werkstofflicher Fehlerfreiheit und der Messung geometrischer Maßhaltigkeit sind in der Mikrosystemtechnik außerordentliche Anforderungen gestellt. Mikro-3D-Röntgen-Computertomograpie (µ-CT) ist eine radiographische zerstörungsfreie Methode, um Werkstückdetails in drei Dimensionen zu lokalisieren. Ein CT-Scanner erzeugt eine Reihe von Röntgen-Absorptionsmessungen, die benutzt werden, um ein rekonstruiertes 3D-Bild des Objektes zu erzeugen. µ-CT kann man einerseits einsetzen, um Bauteile zerstörungsfrei auf eventuelle Fehler zu prüfen und anderseits kann man die Bauteile in drei Dimensionen geometrisch vermessen. In dieser Publikation untersuchen wir die Anwendungsmöglichkeiten von µ-CT für die Charakterisierung und Vermessung von Mikrobauteilen. Wir erörtern diverse Beispiele und berichten über typische Werkstoff- und Bauteilfehler, die mit CT detektiert werden können. Ein weiterer Aspekt ist die Messung von geometrischen Größen wie z.B. Abstände, Dickenprofile und Bohrungsdurchmesser. Wir berichten, auf welche Art und Weise und mit welcher Genauigkeit Geometrien messbar sind. Die Messergebnisse und insbesondere die erreichbaren Genauigkeiten werden mit alternativen Messverfahren verglichen. Es werden die Grenzen der konventionellen 3D-Computertomographie in Bezug auf Mikrobauteile aufgezeigt und darüber hinaus die Anwendbarkeit einen neuen CT- Messmodus für flache Bauteile (Region of Interest-CT-Modus) auf die Problemstellungen der Mikrosystemtechnik untersucht. Dieser Messmodus ist insbesondere in der Si-basierten Mikrosystemtechnik sehr relevant, weil hier häufig planare Strukturen wie z.B. Elektronikleiterplatten oder Strukturen auf einem Si- Wafer zu prüfen sind.
We present a new algorithm, called marching cubes, that creates triangle models of constant density surfaces from 3D medical data. Using a divide-and-conquer approach to generate inter-slice connectivity, we create a case table that defines triangle topology. The algorithm processes the 3D medical data in scan-line order and calculates triangle vertices using linear interpolation. We find the gradient of the original data, normalize it, and use it as a basis for shading the models. The detail in images produced from the generated surface models is the result of maintaining the inter-slice connectivity, surface data, and gradient information present in the original 3D data. Results from computed tomography (CT), magnetic resonance (MR), and single-photon emission computed tomography (SPECT) illustrate the quality and functionality of marching cubes. We also discuss improvements that decrease processing time and add solid modeling capabilities.
The aim of our study was to evaluate the pathological anatomy of the ligaments, tendons and muscles in clubfeet, and to show whether the dysbalance of shortened and elongated structures is an adaptive process or a primary factor inducing the misshaped bones and cartilagines.
Surgical exposure was performed on seven idiopathic clubfeet specimens, aborted between the 25th and 37th week of gestation and compared to two normal feet (27th and 36th week of gestation).
The medial stabilisation system of the foot was found shortened, but all ligaments could be dissected. On the lateral side, the calcaneofibular ligament in particular was both 'shortened' and 'elongated', depending on the course of the fibres to the axis of motion in the subtalar and talocalcaneonavicular joint. The main difference to the normal feet was found in the thickened tendon of the tibialis posterior forming a bulbus before dividing into fascicules.
We presume the ossification disturbance of the calcaneus to be the primary fault. This disturbance will influence the reduction of the varus position, so ligaments and tendons will be conformed to the misshaped bones.
The aim of our study was to elucidate the gross anatomical changes of bones and joints in idiopathic clubfeet.
Gross dissection was carried out on seven idiopathic clubfeet of fetuses aborted between the 25th and 37th week of gestation and compared to two normal feet (27th and 36th week of gestation). Particular attention was paid to the articular surfaces, shapes and angles of all bones and their skeletal relationships.
The talar neck-trochlea angle in clubfeet ranged from 37 degrees to 41 degrees , in normal feet from 27 degrees to 33 degrees . In clubfeet the deviation of the neck of the talus relative to the body was between 28 degrees and 43 degrees , in normal feet between 22 degrees and 24 degrees . The posterior joint surface was in an anterolateral position and even flat transversely. The head of the clubfeet tali was turned along a longitudinal axis in the opposite direction compared to the normal ones. Instead of a typically saddle-shaped posterior talar surface of the calcaneus, it was triangular and flat transversely, and a bony stability in the subtalar joint was not achieved. The angle of torsion of the calcaneus showed no significant difference between normal and clubfeet. The anterior surface was flat, medially twisted and orientated upwards.
We presume that the calcaneus is the primary fault, which might be explained by pathologic biomechanical forces during development.
Advances in imaging and computerized analyses have enabled three-dimensional bone motion in the treated clubfoot to be measured precisely. Three-dimensional translations and rotations of the talus, calcaneus, navicular, and cuboid of surgically treated clubfeet were less in magnitude and sometimes different in direction (or without motion in a specific plane) compared with the contralateral normal feet. Surgical techniques used for clubfoot treatment do not restore normal hindfoot bone motion when examined with high-resolution magnetic resonance imaging, computer reconstruction, and image analysis techniques. These data advance the knowledge of hindfoot bone motion and establish a new and quantitative objective.
Modern quality standards require highly optimized production methods. For this purpose, reliable inspection techniques are needed. To date, the quality control is performed with a variety of different tools. Inner structures of complex bodies can often not be evaluated because of limitations of the measuring devices. A 3D X-ray tomography system is described that allows the inspection of components of any complexity. With a single scan, 3D objects can be reconstructed and any virtual slice inside the object can be analyzed. Since both material and geometry data can be retrieved from the measurement, the results can be used for the detection of flaws as well as for the investigation of geometrical and material variations. An analysis of the 3D shape and position of flaws, dimensional measurements of inner and outer structures and a comparison of the measured geometry with CAD data can be carried out.
An especially low-odor embalming technique was developed over a 30-years-period using a totoal of 977 complete cadavers, numerous cadavers after autopsy, and in vitro series of fresh beef. The color, consistency, and transparency of the tissue were very well preserved. The technique met high standards of preservation without releasing harmful substances into the environment. Concentrations of formaldehyde in room air remained under the limit of detection by Dräger capillaries. The efficacy for disinfection of the method was confirmed by bacteriologic tests. None of the cadavers or samples developed molds.
An especially low-odor embalming technique was developed over a 30-years-period using a total of 977 complete cadavers, numerous cadavers after autopsy, and in vitro series of fresh beef. The color, consistency, and transparency of the tissue were very well preserved. The technique met high standards of preservation without releasing harmful substances into the environment. Concentrations of formaldehyde in room air remained under the limit of detection by Dräger capillaries. The efficacy for disinfection of the method was confirmed by bacteriologic tests. None of the cadavers or samples developed molds.
The clinical characteristics of clubfoot suggest a relative hypoplasia of the posterior and medial foot and leg. To test this hypothesis we compared quantitative cell and organelle characteristics between anterior and posterior tibial tendon sheaths from four clubfeet and two normal feet. Clubfoot posterior tibial tendon sheath had significantly less cell and cytoplasm volume than did clubfoot anterior sheath. Normal posterior tibial tendon sheath had significantly greater cell and cytoplasm volume than did normal anterior sheath. A similar tendency was found for nuclear volume and cell number, although not all samples reached statistical significance. No difference in organelle characteristics between anterior and posterior sheaths was found. We interpret this morphologic difference as suggesting a relative inactivity of clubfoot posterior tibial tendon sheath cells. This supports the hypothesis of a regional growth disturbance as the cause of clubfoot.
Clubfeet must be classified according to severity to obtain reference points, assess the efficacy of orthopaedic treatment, and analyze the operative results objectively. A scale of 0-20 was established on the basis of four essential parameters: equinus in the sagittal plane, varus deviation in the frontal plane and derotation around the talus of the calcaneo-forefoot (CFF) block and adduction of forefoot on hindfoot in the horizontal plane. Four grades of clubfeet can be individualized: (a) Benign feet so-called "soft-soft feet," grade I, similar to postural feet, with a score of 5 to 1 (these mild feet must be excluded from any statistics as they tend to increase good results); (b) moderate feet, so-called "soft > stiff feet," grade II (reducible but partly resistant, with a score of 5-10); (c) severe feet, so-called "stiff > soft feet," grade III (resistant but partly reducible, with a score of 10-15); and (d) very severe, pseudoarthrogryposic feet, so-called "stiff-stiff feet," grade IV (score of 15-20 points). To avoid risks of errors, our method is based on a very complete checklist and on diagrams. Our training material inculdes an audiovisual package.
The ossification of the fetal calcaneus was studied in a series of plastinated sections of 44 normal feet and three clubfeet. The results documented a precise sequence of perichondral and endochondral ossification in the normal calcaneus characterized by ossification grooves and associated cartilage canals. Within the clubfoot calcaneus, the coordination of perichondral and endochondral ossification is disturbed, ossification grooves and associated cartilage canals are not found in regular positions, and the process of endochondral ossification obviously is disturbed. The findings in the clubfoot specimens point to grave irregularities of the extracellular matrix within or outside the calcaneus.
We studied in vivo the talonavicular alignment of club foot in infants using MRI. We examined 26 patients (36 feet) with congenital club foot. The mean age at examination was 9.0 months (4 to 12). All analyses used MRI of the earliest cartilaginous development of the tarsal bones in the transverse plane, rather than the ossific nucleus. The difference in the mean talar neck angle (44.0 +/- 8.1 degrees) in club foot was statistically significant (p < 0.001) when compared with that of the normal foot (30.8 +/- 5.5 degrees). The difference between the mean angles in the group treated by operation (47.9 +/- 6.7 degrees) and those treated conservatively (40.1 +/- 7.5 degrees) was also statistically significant. The anatomical relationship between the head of the talus and the navicular was divided into two patterns, based on the position of the mid-point of the navicular related to the long axis of the head. In the operative group, 18 feet were classified as having a medial shift of the navicular and none had a lateral shift. In the conservative group, 12 showed a medial shift of the navicular and six a lateral shift. All nine unaffected normal feet in which satisfactory MRI measurements were made showed a lateral shift of the navicular. Club feet had a larger talar neck angle and a more medially deviated navicular when compared with normal feet. This was more marked in the surgical group than in the conservative group.
As the navicular is unossified in infants with foot deformities, until 5 years old (boys) and 3 years old (girls), it is difficult to give the exact position of hindfoot bones. Magnetic resonance imaging associated with three-dimensional reconstruction allows the visualization of the cartilaginous volume of the bones and the measurement of the relationships of the navicular with the talus. In normal feet, we noted that in the coronal plane the navicular was laterally situated (75%) relative to the talus. In club feet (17 patients), the navicular and the cuboid had a large medial displacement (77%) with a slight pronation movement in the sagittal plane. In suspected skewfoot (seven feet) we noted three cases with a lateral subluxation of the navicular. This objective technique of measurement may be of value for diagnosis and treatment of foot deformities.
We generated an anatomically detailed, three-dimensional (3-D) reconstruction of a human foot from 286 computerized topographic (CT) images. For each bone, 2-D cross-sectional data were obtained and aligned to form a stacked image model. We calculated the inertial matrix of each bone from the stacked image model and used it to determine the principal axes. Relative angles between the principal axes of the bones were employed to describe the shape of the foot, i.e., the relationships between the bones of the foot. A 3-D surface model was generated from the stacked image models and a detailed 3-D mesh for each bone was created. Additionally, the representative geometry of the plantar soft tissue was obtained from the CT scans, while the geometries of the cartilage between bones were obtained from the 3-D surface bone models. This model served dual purposes: it formed the anatomical foundation for a future finite element model of the human foot and we used it to objectively quantify foot shape using the relationships between the principal axes of the foot bones.
Magnetic resonance imaging (MRI) can clearly visualize both the ossification centers and surrounding cartilage of growing bones and enable a three-dimensional analysis of their positional relationships by using overlapping images. The calcaneal position was evaluated based on five newly proposed parameters of magnetic resonance images in 30 clubfeet of 18 infants with the bimalleolar and lower leg axes as reference lines. Sixteen unaffected feet in the unilateral cases were analyzed as normal feet. MRI showed that the calcaneus in clubfoot rotated internally, medially and posteriorly with reference to the bimallelar axis and that it took an equinus and a varus position with reference to the lower leg axis as compared with the normal foot. These five parameters and their normal values on the calcaneal position should be useful for the evaluation of infantile clubfeet.
To evaluate the morphological deformity of talus in congenital clubfoot by three-dimensional MRI.
Subjects were five patients (two male, three female, mean age 5 months) with unilateral congenital clubfoot. Magnetic resonance imaging was performed of both feet using 1.5 T magnet. Based on the resulting magnetic resonance imaging volume data, a three-dimensional surface bone model was reconstructed by the Marching Cubes method. The long axis of the reconstructed model was determined, and in relation to the standard planes including this axis, the degree of talar head and neck deviation, and the relative positioning of the talus and navicular in the talonavicular joint were compared between normal foot and clubfoot.
The talar head and neck angle in relation to the talus exhibited significant medial deviation in the clubfoot, but the degree of plantar deviation of the talar head and neck did not show significance. The navicular was located more medially in clubfoot than in normal foot. The volume of the total talar and of the ossific nucleus for the clubfoot was smaller than that for the normal foot.
The assessment technique presented herein was shown to be useful in ascertaining the various pathological characteristics associated with clubfoot.
Radiographic measurement is the usual method used to objectively determine the extent of a congenital clubfoot deformity. Although radiographs have been used clinically to estimate the size and location of tarsal bones through measurements of the ossific nuclei, it is not clear to what extent these relationships are actually reflected in these measurements. So, we used a 3-D MRI system that could more objectively estimate sizes and positional relationships.
We evaluated 5 patients with unilateral congenital clubfoot deformity. Magnetic resonance imaging was performed of both feet using 1.5-T magnet. Based on the resulting magnetic resonance imaging volume data, a three-dimensional surface bone model was reconstructed by the Marching Cubes method. We used this model to perform a comparative analysis of the volume and volume ratio of each cartilaginous anlage and ossific nucleus, the length of the talus and the calcaneus, and the position of the center of gravity of ossific nuclei within the cartilaginous anlagen. We measured the relationship between the ossific nuclei and cartilaginous anlagen in the talus and calcaneus of patients with unilateral clubfoot deformity.
In clubfeet talus volume was reduced by 20.1% and calcaneal volume was reduced by 15.7%. Furthermore, the volume of the talar ossific nucleus was reduced by 42.6% and that of the calcaneal ossific nucleus was reduced by 12.1%. The length of the clubfoot talus was 8.2% shorter than normal, and that of the calcaneus was 4.8% shorter.
The assessment technique presented herein was shown to be useful in ascertaining the various pathological characteristics associated with clubfoot.
Knowledge of hind foot bone motion is important for understanding gait as well as various foot pathologies, but the three-dimensional (3D) motion of these bones remains incompletely understood. The purpose of this study was to quantify the motion of the talus, calcaneus, navicular, and cuboid in normal adult feet during open chain quasi-static uniplanar plantar flexion motion. Magnetic resonance images of the right feet of six normal young adult males were taken from which 3D virtual models were made of each hind foot bone. The 3D motion of these models was analyzed. Each hind foot bone rotated in the same plane about half as much as the foot (mean 0.54 degrees of bone rotation per degree of foot motion, range 0.40-0.73 degrees per degree of foot motion as measured relative to the fixed tibia). Talar motion was primarily uniaxial, but the calcaneus, navicular, and cuboid bones exhibited biplanar (sometimes triplanar) translation in addition to biaxial rotation. Net translational motions of these bones averaged 0.39 mm of bone translation per degree of foot motion (range 0.06-0.62 mm per degree of foot motion). These data reflect the functional anatomy of the foot, extend the findings of prior studies, provide a standard for comparison to patients with congenital or acquired foot deformities, and establish an objective reference for quantitatively assessing the efficacy of various hind foot therapies.
Buckwalter JA of clubfoot tendon sheaths Classification of clubfoot
- Fr Dietz
- Iv Ponseti
- H Bensahel
- Ph Souchet
- Ph Mazeau
- Bonnet
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Anatomical study for an update comprehension of clubfoot. Part II: ligaments, tendons and muscles online version: http://www.springerlink.com/content/1863-2548. doi 10
- G Windisch
- F Anderhuber
- Haldi
- V Brändle
- Exner
- G Windisch
- F Anderhuber
- Haldi
- V Brändle
- Exner
A threshold selection method from grey level histograms Three-dimensional hindfoot motion in adolescents with surgically treated uni-lateral clubfoot
- C Otsu N Roche
- B Mattingly
- Md
- Vt
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A Memoir on the Congenital Club Feet of Children, and on the Mode of Correcting that Deformity . Translated from Italian by The pathological anatomy of talipes equino-varus
- Scarpa
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Advanced applications of computed tomography by com-bination of different methods Marching cubes: a high resolution 3D surface construction algorithm
- J Kastner
- D Heim
- D Salaberger
- C Sauerwein
- Simon
Kastner J, Heim D, Salaberger D, Sauerwein C, Simon M (2006) Advanced applications of computed tomography by com-bination of different methods. In 9th European Conference on Non-Destructive Testing, Proceedings CD, Berlin, Germany. Lorensen W, Cline H (1997) Marching cubes: a high resolution 3D surface construction algorithm. ACM SIGGRAPH Com-puter Graphics 21, 163–166.
Die Konservierung ganzer Leichen in nat?rlichen Farben [the Preservation Whole Corps with Natural Color]
- W Thiel
Advanced applications of computed tomography by combination of different methods
- J Kastner
- D Heim
- C Salaberger
- M Sauerwein
- Simon
Anatomical study for an update comprehension of clubfoot. Part I: bones and joints
- Windischg Anderhuberf Haldi-Brändlev Exnergu
Anatomical study for an update comprehension of clubfoot. Part II: ligaments tendons and muscles
- Windischg Anderhuberf Haldi-Brändlev Exnergu