Introduction: Neuro-vascular injuries, complications are common due to misplaced pedicle screws. Literature review shows accuracy from 27.9% to 97% of pedicle screw (thoracic and lumbar) insertion if inserted free hand. Computer Assisted Navigation (CAN) has shown reduction in complications, lesser radiation, and importantly better screw placement accuracy. Objectives: The study aimed at evaluation of pedicle screw placement accuracy using a skin marker-based optical surgical navigation system for minimally invasive and open thoraco-lumbar-sacral pedicle screw placement. Methods: Prospective case series from 9/2021 to 12/2022 where study was done in hybrid operating room with video camera-based navigation installed in imaging hardware. Non-invasive skin markers were used to track patients with an on shaft optical marker pattern. Gertzbein grading system was used by 2 independent reviewers to assess the accuracy of pedicle screw placement by pre and post CT, evaluation of placement time and radiation to surgeons and patient was calculated. Results: From 20 patients, total of 200 screws were evaluated. An overall accuracy of 99% was achieved. (10 % in thoracic, 80 % in Lumbar and 10 % in Sacral region). All screws were placed in Gertzbein Grade 1-2 except 1 was Grade 3. No screw was placed >4mm of cortical breach (Gertzbein grade 4). Average time for screw placement was 5 minutes and 20 seconds (+/- 2 min and 30 seconds). The mean operator radiation dose was 45.3 µSv. The mean patient effective dose (ED) was 13.94 mSv. Conclusion: Computer-assisted optical navigation shows promising accuracy of thoracolumbosacral pedicle screw placement.

Introduction: In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways and have major cost saving implications for healthcare providers. The objectives of this study were to compare LOS and discharge dispositions following robotic arm assisted Total Hip Arthroplasty (RO THA) versus conventional technique (CO THA).

Methods: This large-scale, single institution study included patients of any age undergoing primary THA (N = 1,732) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, Post Anaesthesia Care Unit (PACU) admission, anaesthesia type, readmission within 30 days and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge.

Results: The median LOS in the RO THA group was 54 hours (34, 78) versus 60 (51, 100) in the CO THA group, p<0.001. Discharge dispositions were comparable between the two groups. In the multivariate model, age, PACU admission, ASA score > 2, female gender, general anaesthesia and utilisation of the conventional technique were significantly associated with LOS > 2 days.

Conclusion: Our study showed that robotic-arm assistance was associated with a shorter LOS in patients undergoing primary THA and no difference in the discharge dispositions. Our results suggest that robotic-arm assistance could be advantageous in partly addressing the upsurge of hip arthroplasty procedures and the concomitant health care burden; however, this needs to be corroborated by long-term cost effectiveness analyses and data from randomised controlled studies.

Introduction: The most important factor for achieving stability in total hip arthroplasty (THA) is accurate implant positioning tailored to individual patient phenotype. It is widely accepted that no universal target exists and variations in spinopelvic mobility mandate adjustments to the surgical plan, bringing to the fore the concept of functional component positioning. This study evaluates functional outcomes and PROMs utilising robotic-arm-assistance (RAA) to achieve functional implant positioning.

Methods: This prospective cohort study includes 150 patients undergoing primary uncemented THA. RAA was utilised to execute the patient-specific plan after attaining CT scan and sitting and standing lateral lumbar radiographs. Radiological parameters pertaining to implant positioning were recorded. The Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score (HOOS) and Forgotten Joint Score (FJS) were assessed pre-operatively and at one year.

Results: Mean inclination was 41.9 ± 3.7, mean anteversion 21.3 ± 2.5, mean combined version 33.4 ± 7.5. After one year, median HOOS was 94.4 (Q1, Q3 80 to 98.8), median OHS 47 (Q1, Q3 42 to 48) and median FJS 93.7 (Q1, Q3 77.1 to 100). Improvement from baseline was statistically significant for all PROMs and ROM. No dislocations occurred in this cohort during the follow up period.

Conclusion: Functional implant positioning utilising RAA yielded excellent PROMs and functional outcomes at one year post-operatively. Patient-specific component positioning was significantly affected by individual spinopelvic motion. Tailored implant positioning and RAA may offer a viable solution in reducing dislocation rates, however comparative studies with larger sample sizes are key for validation.

Background: Pedicle screw placement during deformity correction surgeries for complex congenital kyphoscoliosis is challenging, due to the grossly altered anatomy and distorted screw placement landmarks. Screw misplacement leads to devastating complications like vascular injury and neurological deficit. Assistive technologies like intraoperative navigation or robotic guidance which can improve screw placement accuracy are costly and not widely available in lower-middle-income countries(LMIC).Methods: Patient-specific 3D-printed models were used for pre-operative planning and as surgical simulators to execute pedicle screw placement for eleven cases(7 males, 4 females) of congenital kyphoscoliosis. A computed tomography(CT) analysis of the model was performed to assess pedicle screw position and make suitable modifications in trajectories prior to the actual surgery. Pedicle screws were placed using free-hand technique according to the planned trajectories. Pedicle screw placement was assessed on a post-operative CT using Gertzbein-Robbins(GR) classification. Clinical and neurological outcomes were analyzed using VAS and ASIA scores.. Results: The mean follow-up was 14.3 +/- 2 (12-20) months.The mean operative time and intraoperative blood loss were, 220.9 +/- 48.5 (180 - 360)min and 376.3 +/- 96.1 (250 - 650)ml, respectively. The screws were intra-pedicular(Gr A) in 91%(102/112) pedicles while, 7.1%(8/112) pedicles showed non-critical breaches (Gr B). No critical breaches were observed. There were no neurological deficits at follow-up. Conclusion:3D-printed patient specific models aid the spine surgeon in understanding the complex anatomy in congenital scoliosis, as well as to simulate the surgery on the model preoperatively, thereby enabling him to avoid pedicle screw misplacement and prevent complications during the surgery, ensuring optimal outcomes.

Background: To investigate the feasibility of using cortical bone trajectory (CBT) screws for bridging fixation in revision surgery for lumbar adjacent segment degeneration and to provide a reference for clinical practice.
Methods: Computed tomography scans of the lumbar spines of 36 patients in our hospital were used. Sixteen males and 20 females with an average age of 65.5±10.5 years (range: 46 to 83 years) were included. Three-dimensional reconstruction was performed using computer software. Screws with appropriate sizes were selected for the L1 to L5 vertebral segments, and traditional pedicle screws were placed using the standard method. After completing screw placement, simulated placement of CBT screws was performed separately. No overlap occurred between the two screws in the process of CBT screw placement, and the placement point and direction were adjusted until screw placement completion. After all screw placement simulations were complete, grading the screws. Results: Three hundred and sixty screw placement simulations were performed in lumbar pedicles, and 72 CBT screws were implanted in each vertebral body of the lumbar spine. The success rates in the L1 to L5 segments were 73.6%, 80.6%, 83.3%, 88.9%, and 77.8%, respectively, and the acceptable rates were 91.7%, 97.2%, 97.2%, 100%, and 91.7%, respectively. The overall success rate and acceptable rate of CBT screw placement in the lumbar spine were 80.8% and 95.6%, respectively. Conclusion: CBT screws are feasible for bridging fixation in lumbar adjacent segment degeneration revision surgery, and the accuracy of screw placement in different lumbar vertebrae varies.

Introduction: This paper comprehensively introduces the clinical application, basic principle, and function of mixed reality technology combined with 3D printing guide clamp device in orthopedics. Method: Mixed reality real-time computing technology combined with 3D printing guide clamp device. Through the three-dimensional reconstruction of the imaging data obtained before surgery, the visual label guide clamp device prepared by computer-aided meter and 3D printing technology was adopted, combined with the PST binocular camera, to conduct spatial positioning of the object with four fluorescent spheres, and obtain the spatial positions of lesions, instruments, and cameras. The parameters of the virtual camera were set to match with the camera so that the virtual model could overlap with the images of real objects captured by the camera, so as to achieve the mixed reality effect and realize the real-time navigation of precision surgery under the guidance of mixed reality. Results: The technical scheme has the advantages of a wide Angle, high positioning accuracy, and high refresh rate, and is not easy to interfere with other light sources. The position accuracy can be less than 0.5mm and the Angle accuracy is less than 1°, which can realize the surgical navigation and channel roaming technology under multiple angles. Through the 3D printing surgical clamping device and real-time guidance of mixed reality, the surgical design plan was realized from the imaging of two/three-dimensional graphics to three-dimensional solid, providing a new personalized and precise treatment method for modern bone science.

Objective: To study the six degrees of freedom (6DOS) motion characteristics of Lenke type 1 adolescent idiopathic scoliosis (AIS) spine in lateral flexion position with three-dimensional image volume fusion. Methods: 10 Lenke type 1 AIS volunteers were scanned in the supine position and fulcrum lateral flexion position by gemstone CT from T. to s. Using the data to establish the model of each vertebral body. The 3D images of two different body positions were fused to obtain the in vivo kinematics data. Results: In the lateral flexion position of the fulcrum, the AV region: the main motion rotation range of each segment was -2．57 o±0．95 o to -1．37 o±0．65o with statistical significance (P< 0.05). The coupled rotation ranges from -2．71o±0．48o to-1．27o±0．49o along the vertical axis, and the coupled flexion ranges from0．19 o±0．85 o to 1．51 o±0．42 o along the coronal axis. Upper vertebra (UEV) region: the main motion rotation range of each segment was -1．91 o±0．76 o to -2．20 o±1．13 o, without statistical significance (P> 0.05). Coupled rotation ranges from 0．18 o±0．47 o to 1．35 o±0．52 o along the vertical axis, coupled flexion ranges from 1.62°± 0.41° to 2.07°± 0.37° along the coronal axis. The main motion rotation range of each segment was 0.79°± 0.63° to 0.73°± 1.009°, which showed statistically significant (P< 0.05). Conclusions: The direction of coupling rotation in the UEV region is the same side as the lateral flexion movement. The direction of the AV and LEV coupling rotation motion is opposite to the lateral flexion motion.

Advances in technology have transformed numerous aspects of daily life, including surgical training. Virtual reality (VR) technology has gained attention as a potential tool for surgical education, but ineffective evaluation of VR surgical training (VRT) programs can lead to inadequate training. To address this, the current study aims to develop an ontology, specifically for total ankle replacement (TAR), which incorporates shared concepts from domains such as anatomy, physiology, biomechanics, and medical terminology. The ontology is used to create an OntoAnkle-based evaluation method, which assesses knowledge and skills related to ankle anatomy, biomechanics, and surgical techniques. The evaluation method uses objective and subjective measures delivered through self-assessment surveys and is compared to a conventional evaluation method that does not use the OntoAnkle ontology. Results demonstrate that the OntoAnkle-based evaluation method provides a more systematic and formal way of assessing knowledge and skills and offers more detailed and specific feedback. The study proposes the use of OntoAnkle-based evaluation for other medical education programs. The OntoAnkle ontology has the potential to improve surgical training programs by providing a comprehensive ontology-based evaluation method. The study contributes to the broader development of ontologies and evaluation methods in medical domains and uses Design Science Research Methodology (DSRM) throughout the thesis. The demonstration of the OntoAnkle-based evaluation method for VR Ankle Surgery provides significant contributions to the general domain of VR evaluation methods literature, primarily focusing on the ontology-based VR evaluation method segmentation.

Background: Conventional standard preoperative planning for Total shoulder replacement (TSA) is orthodox among surgeons. 2D radiographic images of the patient’s glenohumeral anatomy are obtained to evaluate the glenoid morphology, version, and inclination. Nevertheless, the use of standard surgical instruments are imprecise for the correction of severe glenoid deformity as well as glenoid component malposition which can lead to poor function, instability (32%) and early loosening (39%). Objective: Proof of concept of Computer assisted surgery (3-D planning and PSI) in TSA to be tested on dry cadaveric specimens to test the accuracy of the software 3-D planning and design of PSI jigs. Patients and Methods: This is an experimental prospective interventional pilot study. Conducted on 20 dry cadaveric specimens; in the Orthopedics Department of both Misr University for Science and Technology and 6Th of October University. All dry cadaveric specimen were chosen according to the eligibility criteria. Software use: Mateialise®MIMCS™, Solidworks®, 3Matic® for planning and evaluation. Results: Quantitative analysis of glenoid component positioning demonstrated a good correlation between preoperative planning and the actual position of the central glenoid guide pin. The use of the preoperative planning system and the patient-specific guide resulted in improved correction of version (P = .34) and improved correction of inclination (P =.20). Conclusion: This in vitro study (part of a wider three-stage pilot study) demonstrates the reliability and precision of preoperative planning software and patient-specific guides for glenoid component placement in TSA.

Introduction: In-hospital length of stay (LOS) and discharge dispositions following arthroplasty represent surrogate measures for improvement in patient pathways and have major cost-saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives were to compare LOS and discharge dispositions following robotic-arm-assisted total (Ro-TKA) and unicompartmental knee arthroplasty (Ro-UKA) with conventional techniques (Co-TKA and Co-UKA). Methods: This large-scale, single institution study included patients undergoing primary TKA (N=1,375) or UKA (N=337) between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for Post-Anaesthesia Care Unit (PACU) admission, anaesthesia type, readmission within 30 days and discharge dispositions. Univariate and multivariate logistic regression models were employed to identify factors related to delayed discharge. Results: The median LOS in the Ro-TKA group was 76 hours (54, 104) versus 82.5 (58, 127) in the Co-TKA group (p<0.001), and 54 hours (34, 77) in the Ro-UKA versus 58 (35, 81) in the Co-UKA (p=0.031). Discharge dispositions were comparable between the groups. A higher percentage of patients undergoing Co-TKA required PACU admission (8% versus 5.2%, p=0.040). Discussion: The study showed that robotic-arm-assistance was associated with shorter LOS in patients undergoing UKA and TKA and no difference in the discharge destinations. Our results suggest that robotic-arm-assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost effectiveness analyses and data from randomised controlled studies.

Introduction: Free-hand acetabular component positioning is largely based on intra-operative assessment of orientation of transverse acetabular ligament and Lewinnek safe zones, both of which are surgeon controlled variables. Robotic technology utilises patient specific CT scans and kinematic navigation, to generate individualistic plan and guide us in cup impaction. The purpose of this study is to validate the use of stereotactic assisted acetabular component placement during THA and to determine if robotic assistance is offering improved precision.

Methods: This prospective observational study was conducted on 50 patients undergoing robotic assisted THA @ Sunshine Bone & Joint Institute, Hyderabad, India. After socket preparation, uncemented press-fit trial acetabular cup is placed manually, based on anatomical landmarks, and its anteversion and inclination assessed with help of stereotactic arrays, using 5 spaced out points on the acetabular cup circumference. Then Robotic arm assisted impaction of the cup is done, as per the individualised plan based on CT scan, and the anteversion and inclination determined in a similar manner. Collected data was analysed using appropriate statistical tools.


Results: The mean cup inclination was 39.2° when placed manually, as compared to 39.8° when done with robotic assistance, having no statistical difference (p=0.46). However, the manually positioned cups had a mean anteversion of 20.9°, as against 23.2° obtained with robotic assistance- a statistically significant difference (p=0.0492)

Conclusion: Robotic Assisted Total Hip Arthroplasty enables more precise and patient-appropriate acetabular component positioning, especially with regards to acetabular anteversion.

Introduction: Navigated TKA is still discussable in the literature. Now orthopаedic surgeons research robotic technologies in TKA. Materials and methods: From 2008 we performed more than 1500 navigated TKA with different deformities. We isolated two groups of patients: 150 navigated TKA and 150 convenient replacements. We divided each group in 3 parts with severe (>20 0) varus, valgus (>20 0) and extraarticular deformities, 50 patients in each group. Mean follow up time in booth groups was 86 months (from 78 to 252). The functional result was evaluated by KSS, Oxford and WOMAC scales. We analyzed navigation protocols in navigated groups. The implant survival evaluated by revision at any reason. Results and discussion: we identified mean implant survival in navigated groups: varus- 92,3%, valgus – 86,4 %, extraarticular deformities - 88,7%. In control group: varus- 89,4%, valgus – 82,4 %, extraarticular deformities - 80,3%. The scales showed better results in navigated groups. The main reason for revision was aseptic loosening, the second reason was infection, and it was almost equal in all groups. Moreover, greater difference was between valgus and extraarticular groups. In valgus deformity additional hyperextension was isolated in 36 cases in navigated group. Navigated distal femur resection can be done more proper by navigation. In extraarticular group the proper cuts by navigation system were proofed by navigation protocols. The grate difference in 8,4% of loosening in control group can be explainable, because in extraarticular deformity it is difficult to do the proper cuts and balancing.

Introduction: Proximal femoral osteotomy (PFO) plays an important role in treatment of numerous paediatric hip disorders. Accuracy in each step of proximal femoral osteotomy is essential to achieve the goal of concentric reduction of the acetabular and femoral head, which has steep learning curve with chance to err, are very common. We did this study to evaluate the accuracy of patient specific pre-contoured plates made by using 3D printing for proximal femoral osteotomy in paediatric hip disorders. Methods: 15 patients of age between 2 to 18 years requiring proximal femoral osteotomy for paediatric hip disorder were included in the study. All patients underwent NNCT pelvis, images of which was exported to 3D software and virtual planning of osteotomy was done on virtual 3D model. Patient specific osteotomy navigation template was designed virtually and STL image of jig was exported to 3D printer. 3D printed Jig was sterilized and used intra-operatively. Intra-operative assessment was done by evaluating feasibility of pre-contoured plate by likert scale. Post-operative correction on radiograph was compared with pre-operative planned correction and analysed statistically. Results: Good degree of correction was achieved in 13 patients (86.67%) with fair correction achieved in 1 patient (6.66 %) and poor correction achieved in 1 patient only (6.67 %). Most common Likert parameter was Neutral (8 cases) followed by very easy (3 cases). Remaining 4 patients were in Easy and Difficult category. Conclusion: 3D planning and patient specific jig can reproduce good results and enhance the accuracy, though has steep learning curve.