Application of additive technologies in anterior correction of idiopathic scoliosis

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INTRODUCTION

Idiopathic scoliosis is a complex three-dimensional (3D) spinal deformity that develops during the periods of rapid growth and results in significant functional and cosmetic impairment. Curves reaching 40° or greater tend to progress throughout life and therefore require surgical treatment [1]. The primary goal of treatment is to stabilize the spine to prevent further progression of the deformity. Currently, posterior correction with spinal fusion remains the gold stan-dard. However, this approach is associated with the risk of adjacent segment degeneration, reduced spinal mobility, and the development of chronic pain, which is particularly concerning in young patients [2, 3, 4].

One of the directions in the evolution of idiopathic scoliosis surgery has become anterior correction. The pioneers of this technique were K. Zielke and A.F. Dwyer. Between 1974 and 1985, 76 procedures using the anterior approach were performed [5]. The primary objectives of these procedures were vertebral derotation and interbody fusion.

A major limitation of these techniques was the loss of mobility within the fixed spinal segments. An alter-native motion-preserving approach is anterior scoliosis correction (ASC) using a dynamic implant system. In addition, this surgical approach can be performed thoracoscopically or through a minithoracotomy, al-lowing patients to undergo faster rehabilitation and return more quickly to their previous levels of physical activity [6, 7, 8, 9, 10].

One of the primary and most challenging tasks for a spine surgeon is the 3D perception and understanding of spinal deformity. To address this challenge, various imaging modalities are employed, accompanied by meticulous preoperative planning. Although different navigation systems have gained increasing popularity in recent years, they are not always readily available. In such cases, 3D printing serves as an alternative solution. This technology enables the pro-duction of life-size patient-specific spinal models, customized drill guide templates, patient-specific implants, and surgical instruments [11].

The aim of the study — to evaluate the clinical and radiographic results of anterior scoliosis correction using additive technologies (3D models and individual guide templates) in the surgical treatment of idiopathic scoliosis in patients with completed or near-completed growth.

METHODS

Study design

Type — a single-center retrospective nonrandomized cohort study.

Eligibility criteria

During the study period, 97 patients with idiopathic scoliosis were evaluated and surgically treated at the N.N. Priorov National Medical Research Center of Traumatology and Orthopedics, including 79 (81.7%) females and 18 (18.3%) males. The mean age was 24.5±6.2 (24 [20; 28]) years. Group characteristics are presented in Table 1.

 

Table 1. Baseline comparison of patient characteristics between groups, M±SD

Parameter		Group 1 (control, n = 33)	Group 2 (3D model, n = 34)	Group 3 (guide templates, n = 30)	p (ANOVA)
Age, years		24.2±6.2	25.3±6.1	24.5±5.7	0.413
Sex	M	7	6	6	0.985
	F	26	28	24	0.932
Weight, kg		67.80±8.50	70.20±7.80	69.10±9.10	0.492
Height, m		1.68±0.09	1.70±0.07	1.72±0.09	0.587
BMI, kg/m2		24.10±2.10	24.30±1.90	24.20±2.30	0.831
Risser sign		4.25±0.28	4.20±0.25	4.18±0.30	0.874

 

All patients underwent ASC. To eliminate the influence of surgeon experience as a confounding factor, all procedures were performed by a single spine surgeon with more than 30 years of experience in spinal surgery.

Inclusion criteria:

• anterior scoliosis correction in patients with completed or nearly completed skeletal growth (ASC, Risser sign ≥ 4);
• idiopathic scoliosis grade III-IV (Cobb angle 26-65°);
• age between 16 and 45 years;
• primary surgical procedure;
• follow-up duration of at least 1 year.

Non-inclusion criteria:

• congenital syndromic neuromuscular scoliosis;
• rigid deformities (mobility index > 60%);
• thoracic kyphosis > 40°;
• impaired bone metabolism (osteopenia or osteoporosis).

Patients were allocated into groups according to the intraoperative navigation method used: Group 1 (control, n = 33) — freehand technique; Group 2 (3D model, n = 34) — visual guidance using a patient-specific 3D-printed spinal model to determine the entry point and trajectory of the Kirschner wire; Group 3 (guide templates, n = 30) — intra-operative use of customized drill guide templates with a predefined awl trajectory, providing accurate 3D orientation of the instrument. All groups were comparable with respect to demographic and clinical characteristics. The type of deformity according to the Lenke classification was not considered in the analysis. The cor-responding data are presented in Tables 1 and 2.

 

Table 2. Preoperative SRS-22 questionnaire results, M±SD

Parameter	Group 1 (control, n = 33)	Group 2 (3D model, n = 34)	Group 3 (guide templates, n = 30)	p (Kruskal-Wallis)
Function	3.2±0.8	3.1±0.7	3.0±0.6	0.874
Pain	2.8±0.7	2.9±0.9	3.0±0.8	0.912
Mental health	3.4±0.7	3.2±0.5	3.3±0.6	0.786
Self-image	2.7±0.8	2.8±1.1	2.9±0.9	0.935
Satisfaction	3.1±0.8	2.9±0.6	3.0±0.7	0.845

 

The following outcome measures were assessed: radiographic parameters (Cobb angle), operative time, intraoperative blood loss, time required for the placement of a single screw, and quality of life as measured by the SRS-22 questionnaire [12].

Study duration

Patient enrollment was conducted between December 2023 and September 2024.

Statistical analysis

A sample size calculation was performed prior to the study. The sample size was sufficient to achieve a significance level of α = 0.05 and a statistical power of (1-β) = 0.8.

The sample size calculation was carried out using G*Power v. 3.1 software (Heinrich Heine University Düsseldorf, Germany). For detecting differences among three groups using analysis of variance (ANOVA) with the following parameters: α = 0.05, power = 0.8, and effect size f = 0.4 (medium), the re-quired sample size was calculated as n = 90. A total of 97 patients were ultimately included in the study, providing sufficient power for the planned statistical analysis.

Statistical analysis was performed using SPSS Statistics v. 25 software (IBM, USA) and Microsoft Excel 2016 (Microsoft, USA).

Continuous variables were described using means and standard deviations (M±SD), medians and quartiles (Me [Q₁; Q₃]), and, where appropriate, minimum and maximum values (min-max). Normality of distribution was assessed using the Shapiro - Wilk test. Comparisons of continuous variables among the three groups were performed using analysis of variance (ANOVA) followed by the Tukey post-hoc test. Equality of variances was assessed using Levene’s test. Because heterogeneity of variances was detected for operative time, time required for the implantation of a single screw, and intraoperative blood loss (Levene’s test, p < 0.05), ANOVA with the Welch correction was applied. Comparisons of SRS-22 questionnaire scores among the groups were per-formed using the Kruskal - Wallis test. For categorical variables, absolute (n) and relative (%) frequencies were calculated. A p-value < 0.05 was considered statistically significant.

Preoperative planning

All patients underwent standard preoperative plan-ning, which included standing X-rays, functional X-rays to assess spinal flexibility, side-bending X-rays (right and left bending tests), a traction X-ray, as well as magnetic resonance imaging (MRI) and computed tomography (CT).

Patients were subsequently allocated into three groups. In Group 1 (control), all screws were implanted using the freehand technique. For patients in Group 2 (3D model), a patient-specific 3D spinal model was manufactured. Kirschner wires with a diameter of 1.8 mm were inserted into the model to indicate the intended screw trajectories, entry points, and directions of insertion. This model was used for intraoperative visual guidance and served as an educational tool to explain the planned surgical procedure to patients. For patients in Group 3 (guide templates), customized drill guide templates were manufactured for each instrumented vertebra, incorporating a predefined optimal screw trajectory. In addition, patient-specific rib templates were produ-ced to facilitate accurate intraoperative positioning.

The spinal models were fabricated from PLA (polylactic acid), whereas the drill guides and rib templates were manufactured from photopolymer resins. All components intended for intraoperative use un-derwent gas sterilization. Screw placement accuracy was evaluated using postoperative CT scans.

Surgical technique

Access to the anterior elements of the spine is achieved through either a thoracotomy or a thoracophrenolumbotomy. For procedures involving the thoracic spine, the approach is performed along the superior border of the ninth rib. However, this approach does not allow screw placement at the Th5-Th8 levels. To facilitate implantation at these levels, we perform a socalled double thoracotomy located three intercostal spaces above the primary incision.

To access the lumbar vertebrae, the incision is extended laterally by 3-5 cm toward the external oblique abdominal muscle. Entry into the thoracic cavity is achieved along the superior border of the tenth rib with the division of its cartilaginous portion. This allows retroperitoneal access following the mobilization of the peritoneum and performance of a phrenotomy. Subsequently, the psoas muscle is detached from the vertebral bodies at the required levels using a periosteal elevator. Vertebral level identification is performed using a long needle inserted into the corresponding intervertebral disc, followed by fluoroscopic verification in the AP view.

The pleura is then incised along the anterolateral aspect of the spine over the planned fixation le-vels. Segmental vessels are coagulated using bipolar electrocautery. Partial nucleotomy is performed at all levels of the deformity to increase segmental mobility. An awl is used to create the screw trajectory within the vertebral body: a single channel is pre-pared in the upper thoracic spine, whereas two channels are created in each vertebra at all other levels. The prepared channels are inspected using a ball-tipped probe and subsequently enlarged with a tap. Hydroxyapatite-coated screws are then inserted into the prepared channels. The position of the implants is verified fluoroscopically in two views. A flexible polyethylene terephthalate tether is placed into the screw heads, and its distal end is secured with a locking nut. Using dedicated instrumentation, sequential segmental tensioning of the tether is performed between adjacent vertebrae, resulting in spinal derotation and deformity correction, after which the tether is definitively secured with locking nuts.

The key difference between the study groups lies in the navigation technique used during screw placement. In Group 2, navigation is based on visual reference to the position and trajectory of K-wires preinstalled in the patient-specific 3D-printed spi-nal model. In Group 3, patient-specific drill guide templates are used. Immediately before the placement of the frame retractor, specially designed rib adapters are attached to the ribs. The retractor blades are then mounted onto these adapters, and gradual rib distraction is performed. Following nucleotomy, the screw trajectory is created using an awl guided by a patient-specific drill guide template positioned on the lateral surface of the vertebral body. A separate guide is manufactured for each vertebra. Each guide contains two predefined channels corresponding to the planned awl trajectories. The contact surface of the guide reproduces the patient-specific anatomical landmarks and contours of the vertebral body at a given level, preventing incorrect positioning. Each guide is additionally marked with the vertebral level for which it is intended.

RESULTS

Radiographic parameters

The median Risser sign score was 4 [4; 5]. The mean number of instrumented vertebrae — 6.85±1.75 (5-11). The mean preoperative Cobb angle was 63.8±1.2°, which decreased to 29.7±3.7° postoperatively. The mean correction rate was 53.6±4.5%.

Patients in all groups demonstrated the maintenance of correction throughout the follow-up period, with no substantial loss of correction observed. Improvement in all preoperative Cobb angle measurements was achieved immediately after surgery. A minor loss of correction (< 5°) was observed in two patients from Group 1 (Table 3).

 

Table 3. Radiographic parameters by group, M±SD

Parameter	Group 1 (control, n = 33)	Group 2 (3D model, n = 34)	Group 3 (guide templates, n = 30)	p (ANOVA)
Preoperative Cobb angle, deg.	62.9±2.1	64.2±2.3	64.3±2.0	0.087
Postoperative Cobb angle, deg.	29.8±3.6	29.6±3.8	29.7±3.7	0.982
Correction, %	52.6±4.8	53.9±4.2	53.8±4.6	0.514

 

SRS-22 questionnaire results

Patients completed the SRS-22 questionnaire pre-operatively and at 3, 6, and 12 months following surgery. The results obtained before surgery and at the 3-month follow-up are presented in Tables 2 and 4. At 3 months postoperatively, the quality of life improved significantly in all three groups (p < 0.0001). Group 3 demonstrated superior outcomes compared with the other two groups in the domains of Pain and Satisfaction (p < 0.0001). No statistically significant differences were found between Groups 1 and 2 for the Function domain (p = 0.624), between Groups 1 and 2 (p = 0.358) and Groups 2 and 3 (p = 0.554) for Mental Health, between Groups 1 and 2 for Self-Image (p = 0.810), or between Groups 1 and 2 for Satisfaction (p = 0.693).

 

Table 4. SRS-22 questionnaire results at 3 months postoperatively, M±SD

Parameter	Preoperative	Group 1 (control, n = 33)	Group 2 (3D model, n = 34)	Group 3 (guide templates, n = 30)	p (Kruskal-Wallis)
Function	3.1±0.7	3.6±0.6	3.9±0.5	4.2±0.4	0.000107
Pain	2.9±0.8	3.5±0.7	3.8±0.6	4.4±0.5	< 0.0001
Mental health	3.3±0.6	3.7±0.5	3.9±0.5	4.3±0.4	< 0.0001
Self-image	2.8±0.9	3.2±0.8	3.5±0.7	4.1±0.6	< 0.0001
Satisfaction	3.0±0.7	3.6±0.6	3.8±0.5	4.5±0.4	< 0.0001

 

At the intermediate-term follow-up (6 months after surgery), no statistically significant differen-ces were identified between Group 1 (control) and Group 2 (3D model) in any SRS-22 domain (p = 0.578). However, patients in Group 3, in whom patient-specific drill guides and rib adapters were used, demonstrated significantly better outcomes in the Pain (p = 0.0002), Satisfaction (p = 0.0239), and Function (p = 0.0431) domains compared with Groups 1 and 2.

At the 12-month follow-up, no statistically significant differences were observed among the three groups in any SRS-22 domain (p = 0.3860).

Blood loss and operative time

Data on intraoperative blood loss, operative time, and time required for the implantation of a single screw are presented in Table 5 and Figure 1.

 

Table 5. Intraoperative blood loss, total operative time, and time required for the implantation of a single screw by group, M±SD

Parameter	Group 1 (control, n = 33)	Group 2 (3D model, n = 34)	Group 3 (guide templates, n = 30)	p (ANOVA)
Total operative time, min.	122.4±18.5	104.7±15.2	97.3±12.8	< 0.0001
Time required for the implantation of a single screw, min.	4.2±0.8	3.0±0.6	2.8±0.4	< 0.0001
Blood loss, ml	178.3±21.5	149.8±18.0	141.2±15.5	< 0.0001

 

Figure 1. Intergroup comparison of operative time (a), time to implant one screw (b), and blood loss (c)

 

Compared with Group 1 (control), operative time in Group 3 (guide templates) was reduced by 25.1 mins (95% CI 17.4-32.8; p < 0.0001), corresponding to a 20.5% decrease. In Group 2 (3D model), operative time was reduced by 17.7 mins (95% CI 10.3-25.1; p < 0.0001), corresponding to a 14.5% de-crease. The difference between Groups 2 and 3 was 7.4 mins (95% CI 0.3-14.5; p = 0.0431), representing a relative reduction of 7.1%.

The use of patient-specific drill guides in Group 3 reduced the time required the for the implantation of a single screw by 1.4 mins (–33.3%; 95% CI 1.1-1.7; p < 0.0001). The use of a 3D-printed spinal model in Group 2 reduced screw implantation time by 1.2 mins (–28.6%; 95% CI 0.9-1.5; p < 0.0001). Blood loss in Group 3 (guide templates) was reduced by 37.1 ml (–20.8%; 95% CI 27.4-46.8; p < 0.0001), whe-reas in Group 2 (3D model) it was reduced by 28.5 ml (–16.0%; 95% CI 19.0-38.0; p < 0.0001).

Complications

The following complications were observed in Group 1 (control): one case of hemothorax, two cases of screw malposition, and two intraoperative rib fractures associated with thoracotomy. In Group 2 (3D spinal model), one case of chylothorax and one intraoperative rib fracture were recorded. No complications were observed in Group 3, in which patient-specific drill guides and rib adapters were used.

Revision procedures were performed for hemo-thorax and screw malposition. Clinically, screw mal-position resulted in contralateral radiculopathy caused by screw penetration into the neural foramen (Figure 2).

 

Figure 2. Foraminal malposition on the contralateral side

 

In cases of intraoperative rib fracture (Figure 3), rib osteosynthesis was not performed. During wound closure, the fractured rib segments were anatomically realigned and carefully sutured to the adjacent superior rib. The fracture site most commonly cor-responded to the point of direct pressure exerted by the edge of the rib retractor. In many cases, the cur-vature of the retractor blade did not match the natural curvature of the rib. A second common fracture location was directly beneath the retractor blade. The use of rib adapters increased congruency between the retractor and the rib and reduced the pressure exerted on the rib by the retractor (Figure 4).

 

Figure 3. Iatrogenic rib fracture during thoracotomy: A — proximal part of the rib; B — distal part of the rib

 

Figure 4. Rib lining for thoracotomy

 

The case of chylothorax was managed successfully with conservative treatment consisting of a fat-free diet and administration of Octreotide.

In our opinion, implant malposition and intraoperative rib fractures were associated with the absence of 3D-assisted technologies. In contrast, the cases of hemothorax and chylothorax were unrelated to the use of additive manufacturing technologies.

DISCUSSION

The primary objective of the present study was to analyze the impact of additive manufacturing technologies on intra- and postoperative outcomes of ASC for idiopathic scoliosis. The obtained results demonstrate that the use of 3D-printed anatomical models and, in particular, patient-specific drill guide templates significantly improves key surgical parameters while maintaining comparable radiographic correction outcomes. To date, the international literature contains no reports on the use of additive manufacturing technologies in ASC for idiopathic scoliosis. Therefore, our study was designed to explore the potential application of 3D printing and its influence on the quality of surgical treatment in patients with idiopathic scoliosis.

Intraoperative blood loss is indirectly related to operative time. Through more comprehensive preoperative planning and preparation, we achieved a reduction in operative time and, consequently, a decrease in blood loss (p < 0.0001). According to A.F. Samdani et al., operative time and blood loss are also influenced by the surgical learning curve [13]. In our opinion, the use of patient-specific guides or preoperative simulation of the procedure on a 3D model facilitates more rapid identification of the screw entry point, trajectory, and fixation levels. However, this is not the only strategy for reducing operative time. S. Mathew et al. perform thoracic instrumentation using video-assisted thoracoscopic surgery in combination with a navigation system [14]. In their discussion, the authors reported that video-assisted thoracoscopic surgery was safer but required substantial training and did not reduce blood loss. In their series, mean operative time decreased from 4.8 hours to 3.3 hours (approximately 30%). In the present study, the use of additive manufacturing technologies resulted in reductions in both operative time and blood loss. The influence of the learning curve can reasonably be excluded because all procedures were performed by a highly experienced surgeon. Therefore, the observed reduction in operative time can be attributed directly to the use of 3D-assisted technologies, which minimize intraoperative decision-making and facilitate faster and more reliable screw placement. In the same publication, the authors also highlighted the use of navigation during thoracoscopic procedures for minimizing implant malposition [14].

According to the available literature, screw malposition during anterior spinal surgery is relatively uncommon and therefore remains insufficiently described. Nevertheless, it may result in severe complications, including perforation of the aorta, esophagus, lungs, or dura mater. In our opinion, the most important clinical finding of the present study is the complete absence of screw malposition in the group treated with patient-specific drill guide templates. In our practice, two cases of screw malposition requiring revision surgery were encountered in the control group. In both cases, foraminal breach on the contralateral side resulted in radiculopathy. In the presence of marked vertebral rotation and torsion, it is not always possible to insert a screw along the intended trajectory. Patient-specific drill guides provide a 3D replication of the optimal preoperatively planned trajectory, thereby virtually eliminating placement errors [15, 16, 17]. Our findings directly support the role of additive ma-nufacturing technologies as a tool for improving surgical safety.

In Group 3 (guide templates), customized rib adapters were used during thoracotomy. In our opinion, their use contributed to a reduction in pain severity during both the early and intermediate postoperative periods (up to 6 months). These adapters distribute the force exerted by the rib retractor more evenly across the rib surface, thereby reducing the risk of rib fracture and iatrogenic injury to the neurovascular bundle located within the costal groove along the inferior border of the rib. According to the SRS-22 questionnaire, no sig-nificant differences between Groups 1 (control) and 2 (3D model) were observed for most domains. The highest level of treatment satisfaction was reported in Group 3 (guide templates), which was accompanied by a significant reduction in pain scores (p < 0.0001). In our view, this finding may be explained by several factors. First, the use of rib adapters likely reduced the invasiveness of thoracotomy and consequently diminished post-operative pain. Second, the shorter operative time may have reduced the overall surgical burden on the patient. However, during long-term follow-up (12 months postoperatively), comparable outcomes were observed across all three groups.

There are limited data in the literature regarding iatrogenic rib fractures associated with thoracotomy. In a study by S.A. Bastone et al., the incidence of rib fractures and their consequences following thoracotomy were investigated [18]. The authors identified two possible causes of iatrogenic rib fractures. The first is a mismatch between the curvature of the rib and that of the retractor blade. During rib spreading, mechanical forces may become concentrated at a single point, resulting in a sharp increase in local pressure. The second cause is the inability to precisely control the force and speed of rib spreading when using a rack-and-pinion retractor. This prevents the thoracic tissues from gradually relaxing and adapting to the applied tension, thereby increasing the traumatic effect of the retractor. Consequently, patients develop persistent pain syndrome during the early postoperative period.

Importantly, the degree of deformity correction (mean correction rate, 53.6±4.5%) did not differ significantly among the study groups. This key radiographic finding indicates that additive manufacturing technologies do not affect the ultimate goal of deformity correction; rather, they serve as tools for optimizing and facilitating the achievement of that goal.

The literature also describes a technique for rib approximation following thoracotomy aimed at reducing the incidence and severity of postoperative pain [19]. According to the authors, this method prevents the compression of the intercostal neuro-vascular bundle by the closure sutures.

The use of 3D models is particularly relevant in spinal surgery because of the complex anatomy of the spine and its close relationship to numerous critical anatomical structures. Careful preoperative planning, identification of screw entry points, and determination of optimal screw angles and trajectories may reduce the risk of complications associated with in-jury to adjacent neurovascular structures [20].

Intraoperative use of patient-specific spinal models may also reduce the surgeon’s reliance on additional imaging modalities, thereby increasing confidence during the procedure. Furthermore, this approach has been shown to shorten operative time and reduce intraoperative blood loss [21].

M. Yang et al. demonstrated the importance of using 3D-printed models for understanding the characteristics of spinal deformities and for determining the optimal surgical strategy [22]. Other studies have also reported higher levels of patient satisfaction when the nature and course of the planned surgical procedure are explained in detail prior to surgery [23].

3D models represent a more accessible and less costly alternative to intraoperative navigation systems. Y.T. Wang et al. reported that reducing dependence on intraoperative navigation may improve the cost-effectiveness of the procedure [21].

The degree of deformity correction was comparable across all three study groups, with no significant differences observed. In our opinion, additive manufacturing technologies should primarily be regarded as tools for improving surgical safety, facilitating surgeon training, and increasing procedural efficiency. Their use affects the accuracy of implant placement rather than the magnitude of deformity correction itself. Previous studies have also compared correction outcomes achieved with and without the use of 3D-printing technologies [24]. According to these authors, additive manufacturing technologies can reduce intraoperative blood loss and shorten screw placement time, particularly for less experienced surgeons; however, overall operative time, degree of deformity correction, and other perioperative outcomes remain largely unchanged.

Study limitations

The present study has several limitations, including its retrospective design, single-center setting, lack of randomization, and heterogeneity of spinal deformities. To draw definitive conclusions regarding the utility of additive manufacturing technologies in anterior scoliosis correction, further data collection and continued investigation of the potential ap-plications of 3D printing are required.

An additional limitation is the variation in deformity types according to the Lenke classification among the included patients, which restricts the generalizability of the findings across all forms of idiopathic scoliosis.

CONCLUSION

The use of additive manufacturing technologies, particularly patient-specific 3D-printed anatomical models and drill guide templates, during ante-rior scoliosis correction for idiopathic scoliosis substantially improves surgical safety. In the present study, the use of patient-specific drill guides reduced operative time by 20.5% and intraoperative blood loss by 20.8% compared with the freehand technique. The rate of screw implantation improved by 33.3%, while no cases of screw malposition were observed in this group. In addition, patients treated with drill guides demonstrated superior outcomes in the Pain and Satisfaction domains of the SRS-22 question-naire. Despite comparable radiographic correction across all groups (mean correction rate, 53.6±4.5%), additive manufacturing technologies proved to be valuable tools for improving surgical accuracy, enhancing procedural safety, and optimizing early postoperative outcomes.

DISCLAIMERS

Author contribution

Kolesov S.V. — study concept and design.

Kazmin A.I. — study concept and design, data acquisition, analysis and interpretation.

Domrachev I.E. — data acquisition, analysis and interpretation, drafting and editing the manuscript.

Shvec V.V. — study concept and design.

Pereverzev V.S. — study concept and design, data acquisition, analysis and interpretation.

Morozova N.S. — data acquisition, analysis and interpretation.

Bagirov S.B. — data acquisition, analysis and interpretation.

Raspopov M.S. — drafting and editing the manuscript, study concept and design, data acquisition, analysis and interpretation.

All authors read and approved the final version of the manuscript. All authors agree to be responsible for all aspects of the work to ensure proper consideration and resolution of all possible issues related to the correctness and reliability of any part of the work.

Funding source. This study was not supported by any external sources of funding.

Disclosure competing interests. The authors declare that they have no competing interests.

Ethics approval. The study was approved by the ethics committee of Association of Orthopaedists and Traumatologists of the Russian Federation (AOTRF), protocol 1/23, 28.12.23.

Consent for publication. Written consent was obtained from the patients for publication of relevant medical information and all of accompanying images within the manuscript.

Use of artificial intelligence. No generative artificial intelligence technologies were used in the preparation of this manuscript.

About the authors

Sergey V. Kolesov

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Email: dr-kolesov@yandex.ru
ORCID iD: 0000-0001-9657-8584
SPIN-code: 1989-6994

Dr. Sci. (Med.)

Russian Federation, Moscow

Arkady I. Kazmin

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Email: kazmin.cito@mail.ru
ORCID iD: 0000-0003-2330-0172
SPIN-code: 4944-4173

Cand. Sci. (Med.)

Russian Federation, Moscow

Ivan E. Domrachev

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Author for correspondence.
Email: VaniaD97@yandex.ru
ORCID iD: 0009-0005-9014-3068
SPIN-code: 1367-3096
Russian Federation, Moscow

Vladimir V. Shvets

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Email: vshvetcv@yandex.ru
ORCID iD: 0000-0001-8884-2410

Dr. Sci. (Med.)

Russian Federation, Moscow

Vladimir S. Pereverzev

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Email: vcpereverz@gmail.com
ORCID iD: 0000-0002-6895-8288
SPIN-code: 8164-1389

Cand. Sci. (Med.)

Russian Federation, Moscow

Nataliya S. Morozova

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Email: morozcito@gmail.com
ORCID iD: 0000-0003-4504-6902
SPIN-code: 4593-3231

Cand. Sci. (Med.)

Russian Federation, Moscow

Samir B. Bagirov

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Email: bagirov.samir22@gmail.com
ORCID iD: 0000-0003-1038-1815
SPIN-code: 9620-7038
Russian Federation, Moscow

Mikhail S. Raspopov

N.N. Priorov National Medical Research Center of Traumatology and Orthopedics

Email: mihail.raspopov74@mail.ru
ORCID iD: 0009-0005-9517-7347
SPIN-code: 1843-2864
Russian Federation, Moscow

References

Supplementary files