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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 105-110

Bone Ninja app as a body image simulation tool for shared decision-making

1 Department of Orthopedic Surgery, Rhode Island Hospital, Brown University, Providence, RI, USA
2 International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD, USA

Date of Submission28-Sep-2019
Date of Decision23-Oct-2019
Date of Acceptance12-Nov-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. John E Herzenberg
International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Schoeneman Building, 2nd Floor, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jllr.jllr_17_19

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Background: Reconstruction of preoperative digital photographs to simulate surgery outcomes is a common practice in esthetic surgery and is proven to enhance shared decision-making. Methods: We used the Bone Ninja app to visualize postoperative results of limb deformity correction. To our knowledge, this is the first attempt to use a body image simulation to predict orthopedic surgery. Results: Two patients decided to undergo surgery only after seeing the postoperative simulation. Two patients reported that the actual postoperative results were identical to the simulation, and one patient said that it was very similar. Conclusion: In the authors' opinion, it is a useful educational tool resulting in lesser decisional conflict and unrealistic expectations, better understanding, and improved satisfaction with results. It also helps surgeons with accurate planning and better judgment regarding esthetics.

Keywords: Body image simulation, decision-making, deformity correction

How to cite this article:
Hambardzumyan V, Herzenberg JE. Bone Ninja app as a body image simulation tool for shared decision-making. J Limb Lengthen Reconstr 2019;5:105-10

How to cite this URL:
Hambardzumyan V, Herzenberg JE. Bone Ninja app as a body image simulation tool for shared decision-making. J Limb Lengthen Reconstr [serial online] 2019 [cited 2022 Dec 1];5:105-10. Available from: https://www.jlimblengthrecon.org/text.asp?2019/5/2/105/274579

  Introduction Top

Many decisions in esthetic and reconstructive surgery do not have clear clinical indications. The reason is that the outcomes and alternatives are not well defined scientifically and the benefit is based on patients' subjective values, judgment, and belief. As part of appropriate practice to manage such controversial encounters and issues, shared decision-making and surgical simulation as a tool to enhance it have gained popularity in recent decades. Many studies in different surgical and medical subspecialties have proven the benefits of shared decision-making for patients and healthcare providers.[1],[2],[3] Shared decision-making is regarded as one of the important elements of evidence-based medicine as it facilitates the patient's understanding of illness and matches the available medical evidence with the patient's expectations.[4]

Preoperative computer simulation of surgical procedures is a common tool for shared decision-making in plastic and esthetic surgery.[4] Preoperative visualization of postoperative results improves patients' comprehension of surgery, decreases anxiety, and sets realistic expectations. In a study of patients' preferences of mastectomy versus breast conserving therapy in early-stage breast cancer, decisional aids were proven to decrease decisional conflict and increase satisfaction with decisions.[5] In a large multicenter survey conducted on 767 patients, a group of plastic surgeons determined the effect of a web-based education program. They found that online educational tools significantly increased patients' satisfaction with visits although time of consultation was also increased. With regard to converting to surgery, online tools have increased the number of patients undergoing surgery although it did not reach statistical significance.[6]

Many studies in facial plastic surgery highlight the use of software-based preoperative digital photographic reconstructions to simulate postoperative outcomes. Most of them mention improved patient satisfaction, better patient–doctor relationships, improved trust in the surgeon's esthetic judgment, and enhancement in surgical planning.[7],[8],[9],[10],[11],[12] These techniques also help to exclude patients with unrealistic expectations and gives them opportunity for critical self-assessment. The accuracy of predicted image when compared with actual after surgery results was 70%–80% in rhinoplasty patients.[8],[9],[11] In a group of Asian rhinoplasty patients, one study reported 86% accuracy of preoperative computer simulation. The authors' conclusion was that simulation is an accurate tool and can be a reliable predictor of results.[13] In another study about peculiarities of Asian rhinoplasty, the authors used Adobe Photoshop Software (Adobe, San Jose, California, USA) to import patients' initial photographs and simulate expected postoperative results. They concluded that preoperative computerized simulation not only improved patient–surgeon communication but also helped surgeons with accurate planning, thus improving the likelihood for success.[14]

In the heavily commercialized field of esthetic plastic surgery, many web-based online tools offer simulation of surgical procedures such as rhinoplasty, breast augmentation, abdominoplasty, and face lift surgery. Applications are available for personal computers and smartphones where patients can insert photographs and adjust according their esthetic taste and perception of beauty. From that viewpoint, another interesting phenomenon is the patients' perception and trust of a web-based educational tool simulating the reconstruction. Historically, the surgeon was the main source of information for patients. However, this has changed with myriads of educational resources available to patients on the Internet. According to a recent study, 56.9% of patients have gathered information from the Internet before their first appointment. Surgeons ranked 4.28/5 on a Likert-type scale of helpfulness, followed by the online simulation tool (3.73) and the Internet (3.6). High-income patients tend to rank surgeons lower.[15] In an effort to evaluate the influence of information sources on the decision-making process for breast augmentation, Walden et al. conducted a survey that revealed that 52% of patients were very much or extremely influenced by the plastic surgeon's web site.[16]

In orthopedic deformity correction and limb lengthening surgery, shared decision-making is one of the main components of patient–physician interaction.[17],[18] It has been shown to reduce the cost and improve care.[19] Decision aids other than postoperative body image simulation have been used effectively to facilitate the process.[18] While we were able to find many examples of body image simulation in cosmetic esthetic surgery, in orthopedic limb deformity correction, such examples are quite scarce. One is from the pioneer limb lengthening surgeon, Heinz Wagner. In CORR article Wagner stressed the importance of patient cooperation for decision-making and published composite photographs to contrast the patient's predicted appearance after two types of surgery: lengthening the short femur versus shortening the long femur.[20]

Modern orthopedic deformity correction frequently uses software for X-ray analysis and planning. Commonly used programs include a variety of picture archiving and communication systems (PACS) programs, TraumaCAD, and Bone Ninja.[21],[22] In preoperative radiographic analysis for deformity angle measurements and planning, Bone Ninja has been shown to be an accurate tool when compared to the gold standard of PACS.[23] Bone Ninja is an application for the Apple iPad which can import photographs from the iPad camera or picture library. We used the former option to import patients' initial clinical pictures into the program and then to simulate postoperative results. The numerical values of angles and centimeters/inches of correction can be derived from the preliminary radiographic analysis on the same Bone Ninja application.

The goal of this effort is to facilitate shared decision-making for patients undergoing limb deformity correction surgery. By visualizing possible outcomes, patients may have fewer decisional conflicts and unrealistic expectations, will better comprehend the proposed surgery, and obtain improved satisfaction with results. We expect also that postoperative simulation will help surgeons with planning and better judgment regarding esthetics. We report three demonstrative cases where preoperative simulations were created using the Bone Ninja application and had a positive effect on shared decision-making.

  Materials and Methods Top

For the first step, the patients' radiographs were imported into the Bone Ninja application. These included the standing lower extremity long anteroposterior films with bilateral pelvis, hip, knee and ankle joints visible, and patellas facing forward. Deformity analysis and reconstruction were done in the usual manner.[24] Measurements included the lateral distal femoral angle, medial proximal tibial angle, total limb length, and the length of separate segments. Images were calibrated either using a 2.54-cm ball or a ruler.

The second step was the modification of the preoperative clinical pictures and postsurgical result simulations. We imported the preoperative clinical standing photographs into the Bone Ninja application and modified them based on the measurements in the radiographs. We superimposed the mechanical axis lines of the separate segments on clinical pictures and added the lines representing the corrected axis according to angles measured on the radiographs. Finally, we generated the postoperative surgery simulation using the “cut” and “rotate” tools in the app.

The initial three patients were photographed before surgery using the iPad's camera. The iPad was a fifth generation device with a 9.7-inch retina display. Images were imported into the Bone Ninja application. Reference lines mimicking the deformities were drawn on thighs and legs. Correction was done using “cut” and “rotate” tools, according to angles measured on the radiographs.

The images (before and simulated after) were shared with the patients by e-mail so that they could discuss them with their extended families. One of the patients received two possible simulated outcomes to choose from. The goal was to decrease the decisional conflict, facilitate, and enhance patients' informed decision-making with visualization of postsurgical results, as well to set a realistic expectation from surgery.

  Results Top

Two patients decided to go ahead with surgery only after seeing the simulation of the postsurgery results. Two patients reported the actual postoperative results to be identical to the simulation, and one patient said that it was very similar to the simulation. All patients demonstrated good understanding and comprehension of the proposed surgery. They were all very satisfied with the initial visit and appreciated seeing the simulation of the after surgery results.

As this is the first attempt to simulate the postsurgical results on clinical images in orthopedic deformity correction using Bone Ninja, we do not have a control group and did not measure the improvement of patient satisfaction. Other outcome measures, including a decrease in decisional conflict and anxiety also should be addressed in future studies.

  Discussion Top

Simulation of body image after esthetic correction is very well known and studied in the cosmetic plastic surgery world. Many positive outcomes have been reported including improved patient satisfaction and patient–surgeon relationship, decreased decisional conflict, and better shared decision-making. These results have been quantified in several subspecialty fields of plastic–esthetic surgery.

However, in orthopedic limb deformity correction, to our knowledge, there are no similar publications. There have been no systematic efforts to simulate postoperative results and elicit patients' perceptions and feedback. From that viewpoint, our study is an initial attempt to fill the gap. The Bone Ninja application has been proven to be a reliable tool for radiographic deformity analysis and correction. We used the deformity correction parameters obtained from radiographs as analyzed by the same app. By the methods described in this article, we generate after surgery simulations of body image. During initial and follow-up encounters, simulated body images were a substantial part of discussion. Our impression is that patients and families felt much more confident regarding their decision. We noticed improved surgeon–patient relationships. Outcome simulations have been a useful educational tool for us. At this time, given the small number of cases and the absence of a control group, we are unable to quantify the outcome measures. However, we believe that in orthopedic reconstructive and esthetic surgery, postoperative body image simulation, regardless of the software used, is an excellent educational tool. It should be noted that preoperative visualization of postoperative images will not predict functional outcomes. Functional outcomes and patient-reported outcomes depend on other factors that are not related to physical appearance and body image simulation.

  Conclusion Top

To our knowledge, this is the first report of simulated body image reconstruction in orthopedic surgery using the Bone Ninja app. It is our impression that postsurgical body image simulation in limb deformity correction and lengthening is a very good educational tool for patients. It is able to enhance shared decision-making, improve patients' satisfaction, and facilitate better patient–surgeon relationship and trust.

Future studies are needed to quantify the patients' perception and feedback of postsurgical body image simulation.

  Case Studies Top

Case #1 A 25-year-old woman presented with bilateral valgus knees, worse on left [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. She could not decide whether to do left side surgery only and have it made identical to match the right with slight valgus knees or do both lower extremities with bilateral maximal valgus correction. We used Bone Ninja to simulate her body image with left only reconstruction and with bilateral reconstruction. Images were given to patient, and after consideration, she opted to have bilateral correction.
Figure 1: Initial clinical picture and radiograph, showing bilateral valgus, worse on the left

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Figure 2: Simulation of left only reconstruction, to match the right side

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Figure 3: Simulation of bilateral reconstruction, to fully correct the deformities

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Figure 4: Comparison of simulated left only versus bilateral reconstruction

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Figure 5: Postoperative radiograph and clinical image and comparison with preoperative body image simulation

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Case #2: A 20-year-old woman, with right valgus knee, presented complaining of cosmetic appearance of right lower extremity [Figure 6], [Figure 7], [Figure 8]. She decided to proceed with surgery after seeing Bone Ninja simulated images.
Figure 6: Preoperative clinical photograph and radiograph

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Figure 7: Bone Ninja simulation of the correction in the clinical photograph and the radiograph

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Figure 8: Postoperative results and comparison with preoperative body image simulation

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Case #3: A 31-year-old man with bilateral varus knees, status post failed high tibial osteotomy on the right [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]. As he had experienced a failed corrective procedure on the right, he was very anxious regarding the outcome of another procedure and wary of doing anything to his left side. After seeing surgery simulations, his confidence improved, decreased anxiety, and he was able to make the decision to treat both legs.
Figure 9: Initial photograph and radiograph showing bilateral varus, worse on the operated right side

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Figure 10: Bone Ninja simulations

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Figure 11: Postoperative results after correction of the right side

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Figure 12: Bilateral reconstruction x-ray and clinical picture during treatment and final outcome

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Figure 13: actual postoperative results

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Financial support and sponsorship


Conflicts of interest

JEH is an employee of Sinai Hospital of Baltimore, which owns and maintains the Bone Ninja app. VH does not have any conflicts to report.

  References Top

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Ewart CJ, Leonard CJ, Harper JG, Yu J. A simple and inexpensive method of preoperative computer imaging for rhinoplasty. Ann Plast Surg 2006;56:46-9.  Back to cited text no. 12
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Parmeshwar N, Reid CM, Park AJ, Brandel MG, Dobke MK, Gosman AA. Evaluation of Information Sources in Plastic Surgery Decision-making. Cureus 2018;10:e2773.  Back to cited text no. 15
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]

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