Innovative imaging-based pre-operative planning for correction of proximal femur malunion with implants in-situ using Picsart and PowerPoint

Abstract

Background

Proximal femoral malunions with implants in-situ pose a significant challenge for pre-operative planning due to the obstruction of key anatomical landmarks. Existing planning software, while advanced, is often limited by cost, accessibility and a lack of functionality for digital implant removal. The main objective is to introduce a novel, low-cost and accessible two-step digital method for planning deformity correction using Picsart and Microsoft PowerPoint.

Methods

This technique employs Picsart, a free photo-editing application, for digital implant removal, followed by Microsoft PowerPoint for deformity measurement and surgical simulation. It allows for angular and rotational assessment, identification of the Centre of Rotation and Angulation (CORA) and planning of corrective osteotomies, external fixation or arthroplasty.

Results

The method supports accurate calibration using antero-posterior and lateral radiographic views and also enables simulation for correction. It is adapted from the Planning for Limb Reconstruction using Slide Presentation Software (PLIRSP) methodology.

Conclusion

This two-step digital approach offers a reproducible and practical alternative for orthopaedic deformity planning. It empowers surgeons and trainees, especially in resource-constrained environments, by enhancing pre-operative precision and encouraging innovation in orthopaedic education and surgical strategy.

Graphical abstract

1. Introduction

Malunion is defined as the healing of a fracture in a non-anatomical alignment, resulting in deviations such as limb length discrepancy (LLD), angular or rotational deformities or a combination of these. These structural abnormalities can lead to functional impairments including pain, abnormal gait patterns and restricted range of motion.¹ Among long bones, the tibia is the most frequent site for malunion, followed by the bones of the forearm.²

Femoral malunions, particularly those involving the proximal femur, represent a notable complication of femoral fractures. Proximal femur fractures alone account for approximately 12 % of all fractures encountered in trauma centres.³ These injuries are usually bimodal in occurrence, observed predominantly in the elderly population, due to low-velocity trauma attributing to the underlying osteoporosis and also in young adults, typically following high-velocity direct trauma to the hip itself.

Despite their frequency, malunions of the proximal femur are relatively rare. This is largely due to the fact that such fractures are generally managed operatively because of their disabling nature. As such, conservative treatment rarely results in malunion. The majority of proximal femoral malunions are post-surgical in origin, arising from factors such as inadequate fracture reduction, sub-optimal implant selection or improper implant positioning.⁴

When patients with a history of surgical fixation present with deformity, pre-operative planning for corrective osteotomy is often complex, particularly due to the presence of hardware in-situ. This adds a unique layer of challenge to deformity analysis and surgical strategy formulation.

Historically, prior to the development of Picture Archiving and Communication Systems (PACS), orthopaedic deformity planning was performed using printed radiographs. Measurements and osteotomy simulations were carried out manually by tracing radiographic outlines onto paper, followed by physical cutting and repositioning, an approach famously described by Paley.⁵

With advances in digital technology and artificial intelligence, numerous applications and software platforms are now available for pre-operative planning on personal computers, tablets and smartphones. Notable tools such as Bone Ninja, OrthoCAD, Bone Setter have significantly simplified the deformity planning process.6, 7, 8 However, these applications often require paid subscriptions and are typically limited to tablet-based use, which may pose accessibility challenges in resource-constrained settings.

To address this gap, Baar et al. introduced a cost-effective technique termed Planning for Limb Reconstruction using Slide Presentation Software (PLIRSP), utilizing common programs like Microsoft PowerPoint and Keynote. This method democratized access to pre-operative planning tools, especially among trainees and surgeons in low-resource environments.⁹

Despite these innovations, a persistent limitation in current software is the inability to digitally remove implants in-situ, which often obscure key anatomical landmarks necessary for accurate planning. While several photo-editing applications such as Adobe Photoshop, Photoroom, AI Ease, Magic Studio and many more offer object removal features, they typically restrict usage through trial limitations or require a monthly subscription for full access.

Picsart, a freely available photo-editing application, offers a unique advantage as it allows multiple attempts at object erasure without cost.¹⁰ This makes it particularly useful for clinical adaptation, even among users without technical expertise or financial resources. We propose a simple two-step digital planning method combining Picsart for implant removal and Microsoft PowerPoint for deformity measurement and pre-operative simulation. This technique provides a low-cost, accessible alternative for planning limb reconstruction in cases with in-situ implants.

2. Description of the simulated pre-operative planning exercise

2.1. Implant removal using Picsart

To begin, the Picsart application must be downloaded on a tablet or smartphone or accessed through a web browser. The tool can be used for free after simple registration. Although the app offers in-app purchases, the features required for this process are available without cost. Once logged in, the user selects the “Remove Objects” function within the app. The desired radiograph is uploaded and the implant is carefully shaded using the removal tool. It is important to zoom in and precisely outline only the implant, taking care not to include the surrounding bone cortices. After marking the implant, the “Remove” button is clicked. If the result is satisfactory, the user applies the changes and exports the final image in .jpg or .png format (Fig. 1).

Fig. 1.

Illustration of the steps for editing a radiograph using Picsart: (A) Begin by inserting the image from the gallery and adjusting the brush size as needed. (B) Proceed to outline the implant area that you wish to erase. (C) Once the erasure is satisfactory, click on the ‘Apply’ option to confirm the changes. (D) After reviewing the edited image, select the ‘Export’ option. (E) Finally, download the modified image to complete the process.

2.2. Measurement and planning using Microsoft PowerPoint

The edited radiograph image is then inserted into Microsoft PowerPoint. For calibration purposes, a transparent scale and protractor image are downloaded via any web browser. Additionally, within the PACS system, a standard straight-line measurement and angle are drawn on a sample radiograph and saved. These reference images are also inserted into PowerPoint. Once inserted, the scale and protractor are adjusted to match the known measurements from the PACS reference image (Figure - 2). This establishes accurate calibration, allowing precise measurement directly on the planning image. For anatomical alignment and consistency, it is recommended to include both antero-posterior (AP) and lateral (Lat) views with 2–3 reference lines drawn across identical anatomical landmarks. This technique is based on and adapted from the Planning for Limb Reconstruction using Slide Presentation Software (PLIRSP) methodology.

Fig. 2.

(A) & (B) showing calibrating of scale and protractor to PACS radiographic measurements.

2.3. Proximal femur planning

Assessment of deformities in the proximal femur requires careful analysis of key radiographic parameters to determine the nature and extent of the malalignment. Important measurements include the Lateral Proximal Femoral Angle (LPFA) and the Medial Neck-Shaft Angle (MNSA), both of which provide insight into angular deviations. Additionally, Mal-orientation Tests (MOT) such as evaluating the alignment of the trochanter-head line and head-neck line are useful for identifying rotational abnormalities.⁹ A bilateral comparison of the lesser trochanter levels further aids in assessing proximal femoral shortening, a common feature in malunited fractures. Once these measurements are obtained, the angle of correction can be accurately determined. Using digital tools in Microsoft PowerPoint, the radiographic images can be manipulated to simulate the correction. This involves cropping, rotating and repositioning the affected bone segments to visually approximate the post-operative outcome. This simulation facilitates pre-operative planning by allowing the surgeon to anticipate the extent of correction required and visualize potential surgical strategies (Fig. 3).

Fig. 3.

Radiographic assessment of a malunited proximal femur in coxa vara after implant erasure. (A) Depicts the femoral head to trochanter line. (B) Shows the measured neck shaft angle. (C) Shows the femoral head-neck line. (D) Shows the lateral proximal femoral angle (LPFA).

2.4. Angular deformities and CORA estimation

In cases of angular deformity, accurate identification of the Centre of Rotation and Angulation (CORA) is essential, as it represents the apex around which the bone is misaligned.¹¹ Determining the CORA enables precise planning of the osteotomy to restore mechanical alignment. To simulate the correction, multiple copies of the radiograph are overlaid and manipulated using Microsoft PowerPoint (Fig. 4). The segment of bone requiring correction is digitally isolated and rotated around the CORA. This adjustment creates either an open or closed wedge, corresponding to the calculated angle of correction necessary to realign the limb. This visual representation provides a practical and reproducible method for pre-operative planning of angular deformities.

Fig. 4.

Images (A) & (B) showing the measurement of CORA and marking the level of osteotomy.

2.5. Planning with external fixation

When planning the use of external fixation devices such as the Limb Reconstruction System (LRS), Ilizarov External Fixator (IEF) or hexapod frames, further image manipulation can be employed to enhance visualization. After marking the CORA and planned osteotomy site, schematic outlines of the external fixator components can be overlaid on the radiograph to provide a conceptual understanding of the final construct (Fig. 5). Though time-consuming, this step is particularly useful for surgical rehearsal and education.

Fig. 5.

Sequential steps for simulating deformity correction using Picsart and PowerPoint: (A) The initial radiograph displays a malunited proximal femur with an implant in situ. (B) After implant removal using Picsart, the mechanical axis is drawn to assess alignment. (C) The level of osteotomy is then identified. (D) Multiple copies of the same image are used to segment the radiograph into proximal and distal parts; the distal segment is rotated by 10° to achieve alignment. (D) and (E) illustrate the simulation of deformity correction using an LRS (Limb Reconstruction System) construct.

2.6. Templating for arthroplasty in complex malunions

In select cases of malunited basi-cervical neck of femur fractures with implants in-situ and significant femoral shortening, the choice between osteotomy and total hip arthroplasty (THA) depends on patient age and bone quality. In patients planned for arthroplasty, pre-operative templating of the acetabular and femoral components can be performed by taking the implant template outlines from a regular total hip replacement radiograph and using the same digital planning process for a malunited proximal femur with osteoarthritis (Fig. 6). The critical aspect is ensuring proper alignment of the centres of rotation for both components.¹²

Fig. 6.

Pre-operative planning for total hip arthroplasty in a case of malunited proximal femur fracture: (A) depicts a post-operative radiograph with a total hip replacement done. (B) Outline the implant to create a template outline for the implants with their centre of rotation and delete the radiograph to retain the outlined image. (C) The initial radiograph displays a malunited intertrochanteric fracture with implant failure (D) After implant removal using Picsart (E) Templating is performed using a roughly sketched prosthesis on both hips; however, on the right side, the centres of rotation of the femoral and acetabular components are misaligned. (F) To correct this, the proximal femur is cropped and distalized to restore the neck-shaft angle and a semi-transparent duplicate of the same image is superimposed to provide a visual reference of the adjustment. (G) Final templating on the right hip demonstrates proper alignment, with both centres of rotation positioned at the same level.

3. Discussion

Pre-operative planning in cases of proximal femoral malunion is a cornerstone of successful deformity correction surgery. However, traditional planning methods often become inadequate when in-situ implants obscure anatomical landmarks critical for accurate deformity assessment and simulation. Advanced planning tools and applications have significantly transformed digital planning workflows, offering features such as angle measurements, templating and simulation of osteotomy corrections. Nevertheless, these applications generally require tablet-specific use and paid subscriptions, potentially limiting their adoption in resource-constrained environments.

Baar's introduction of PLIRSP (Planning for Limb Reconstruction using Slide Presentation Software) marked a key step toward democratizing access to digital deformity planning.⁹ The method harnessed widely available platforms like PowerPoint and Keynote, allowing orthopaedic professionals to conduct planning without costly or specialized software. The current study builds on this foundation by integrating Picsart, a free and versatile image-editing tool, to virtually remove obstructive implants, an area where existing digital tools fall short.¹⁰

This novel two-step approach using Picsart for digital implant removal and PowerPoint for measurement, angular analysis and osteotomy simulation addresses two key gaps in orthopaedic planning: cost-effective accessibility and visualization of obscured anatomy. Importantly, this method supports the identification of the Centre of Rotation and Angulation (CORA), a pivotal component in deformity correction planning.^11,12 Simulation of correction and potential strategies such as external fixation or arthroplasty templating can also be implemented, promoting comprehensive pre-surgical visualization and rehearsal.^12,13

While this workflow does not replace formal templating software or PACS-integrated systems, it offers a pragmatic solution where resources are limited and time is of the essence. Its adaptability makes it especially valuable for training institutions, early-career surgeons and practitioners in low-income regions.

Despite its practicality, the technique described has several limitations. Primarily, it remains a descriptive and illustrative method without extensive validation. There is a lack of case-control or comparative studies to evaluate outcomes against conventional digital planning software. Also, there are neither any longitudinal clinical outcome data to validate the efficacy of surgical plans developed through this method nor standardized protocols or user-interface enhancements to ensure reproducibility across different users.

Future studies should aim to systematically validate this method through clinical trials, interobserver reliability assessments and comparative outcome analyses with existing planning platforms.

4. Conclusion

Pre-operative planning in the presence of proximal femoral malunion with in-situ implants poses unique challenges, particularly due to the obstruction of anatomical landmarks by retained hardware. Traditional high-cost planning software may be inaccessible in low-resource settings and even available tools often lack the functionality to digitally remove implants, limiting their applicability in such complex cases.

The combined use of Picsart for implant erasure and Microsoft PowerPoint for deformity assessment offers a cost-effective, accessible and reproducible solution for orthopaedic surgeons and trainees. This method facilitates detailed planning through accurate measurements, deformity simulation, CORA analysis and even external fixator configuration or arthroplasty templating. By leveraging widely available digital tools, this approach empowers surgeons regardless of their technological or economic constraints to develop precise surgical strategies for deformity correction.

Ultimately, this novel two-step technique enhances the surgeons’ ability to plan effectively, promotes educational innovation and may contribute to improved surgical outcomes in cases of proximal femoral malunion with retained implants.

CRediT authorship contribution statement

J.S.R.G. Saran: Conceptualization, Methodology, Software, Investigation, Writing – original draft. Sandeep Reddy: Validation, Resources, Writing – review & editing, Supervision. Varun D: Visualization, Investigation, Writing – review & editing, Supervision. Durai Anand: Software, Resources, Writing – review & editing, Supervision.

Ethical approval

The article was followed up only after obtaining Ethical clearance.

Consent

Consent from the patients was taken prior to conducting this study.

Ethical statement

The article was followed up only after obtaining Ethical clearance.

Funding

No funding was used for this case report.

Conflict of interest

No conflicts of interest amongst the contributing authors.