Deformity Correction Planning Utilizing A Mobile Device Application

Noman A. Siddiqui, DPM, Corine L. Creech, DPM, and Bradley M. Lamm, DPM, FACFAS

Radiographic analysis for surgical intervention involving the foot and ankle has historically been recognized as a vital component of pre-operative planning.1 This is especially true when dealing with complex foot and ankle deformities.2 The advent of digital radiology has made the process of radiographic evaluation one of greater convenience and reproducibility.3 The creation of programs available for computers, smartphones and tablets has made it possible for busy surgeons to have these images at their fingertips.

   Prior to using digital radiographs, surgeons were forced to rely on more traditional methods of preoperative planning, including tracing paper cutouts, acetate templates and PowerPoint manipulations. The availability of PACS (picture archiving and communication systems), which stores digital images, has replaced traditional radiographic films. The use of computerized digital radiographs makes transmission of material easy and quick.

   A recent study in US Radiology noted that “Digitalized radiography has become the standard modality in most orthopedic centers in industrialized countries over the past decade, creating the need for digitalized templating for the purposes of surgical planning.”4 Access to these digital images are available to physicians at hospitals and private practices as well as by remote login.5 This convenience has led to the advancement of computer software tools. Surgeons now have the ability to download these digital images for manipulation, measuring and planning via various commercial-based radiology software.

   Although basic digital radiology software allows for measurement of distances and angles, many are not equipped with tools essential for performing deformity correction planning. Advancements in mobile technology software in the form of applications on computers, tablets and smartphones have changed how many surgeons are using digital photographs in planning for deformity correction.

   One such application that is transforming the way surgeons plan for common to complex orthopedic procedures is Bone Ninja (Sinai Hospital, Baltimore). Bone Ninja is an application that was first introduced at the 2012 Baltimore Limb Deformity Course and is now available through Apple iTunes. Bone Ninja is an educational tool that allows users to upload a digital radiograph,plain film radiograph or even a photo of a radiograph for manipulation, measuring and deformity planning.

   Physicians can use the program for assessment of length, angulation, translation and alignment. Special tabs within the application allow for placement of osteotomies, angulation/rotation of selected segments, the addition of internal/external fixation and other deformity correction-related tools. In addition, the Bone Ninja comes with a feature of image calibration, which authors have shown to be essential in using digital programs to accurately measure radiographs.6 The program also provides preloaded deformity cases with corrected solutions. These cases are available for those who wish to practice and gain experience in deformity planning principles.

What The Literature Reveals About Digital Radiographs And Pre-Op Planning Protocols

The medical and surgical literature has numerous examples of using digital radiographs in preoperative planning protocols. In particular, the use of computer programs, such as TraumaCad, reportedly provides essential tools in appropriately measuring limb length discrepancy.4 TraumaCad is a program that was developed for deformity planning and templating for many orthopedic procedures. Drs. Siddiqui and Lamm have an article in press for publication utilizing this software for the correction of flatfoot deformity. We found that utilizing the TraumaCad software accurately can predict the bone graft sizes needed for complete flatfoot correction with the Evans calcaneal osteotomy.

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