The efficacy of "TiRobot"orthopaedic robot-assisted VS conventional fluoroscopic percutaneous screw fixation of the sacroiliac joint

[Effectiveness analysis of 5G remote robotic surgery in pelvic fracture treatment]

Objective

To investigate the effectiveness of 5G remote robotic surgery in the treatment of pelvic fractures.

Methods

A retrospective analysis was conducted on the clinical data of 160 patients with pelvic fractures admitted between July 2023 and June 2024 who met the selection criteria. Among these patients, 80 underwent internal fixation surgery with the assistance of 5G remote robotic surgery (5G group), while 80 received local robotic surgical assistance (control group). Baseline characteristics, including gender, age, body mass index, disease duration, cause of injury, and fracture classification, were compared between the two groups, and no significant difference was found ( P>0.05). The incision length, operation time, intraoperative blood loss, hospital stay, accuracy of screw placement, maximum residual displacement postoperatively, quality of fracture reduction, incidence of complications, Majeed pelvic function score and classification at last follow-up were recorded and compared between the two groups.

Results

In the 5G group, 180 screws were implanted during surgery, while 213 screws were implanted in the control group. The 5G group demonstrated significantly reduced intraoperative blood loss and shorter incision length compared to the control group ( P<0.05). No significant difference was observed between the two groups in terms of operation time or hospital stay ( P>0.05). Radiographic evaluation revealed excellent and good reduction rates of 98.8% (79/80) in the 5G group and 97.5% (78/80) in the control group, while excellent and good screw placement accuracy rates were 98.3% (177/180) in the 5G group and 95.8% (204/213) in the control group. No significant difference was found between the two groups in maximum residual displacement, reduction quality, or screw placement accuracy ( P>0.05). All patients were followed up 7-16 months (mean, 11.3 months), with no significant difference in follow-up duration between the groups ( P>0.05). No perioperative or follow-up complication, such as wound infection, iatrogenic fractures, iatrogenic neurovascular injury, screw loosening or breakage, or nonunion, were observed in either group. The control group exhibited a worse degree of gait alteration compared to the 5G group ( P<0.05), while no significant difference was found in incidences of squatting limitation or persistent pain ( P>0.05). At last follow-up, no significant difference was observed between the groups in Majeed pelvic function scores or grading ( P>0.05).

Conclusion

Compared with the local surgery group, 5G remote robotic surgery supported by remote expert technical guidance demonstrated smaller incision lengths, less intraoperative blood loss, and fewer postoperative complications, and was shown to be a precise, minimally invasive, safe, and reliable surgical method.

TiRobot ForcePro Superior combined with suture-button plates for minimally invasive treatment of an acetabular both-column fracture - a case report

BACKGROUND

The acetabulum exhibits an irregular anatomical structure with a dense concentration of critical blood vessels and nerves in its vicinity. Acetabular fractures accompanied by periarticular soft tissue injuries may lead to life-threatening complications. The Letournel-Judet classification system is currently the widely adopted standard for categorizing acetabular fractures, with the both-column fracture type recognized as the most complex pattern within this framework. Open reduction and internal fixation remains the gold standard for its management. The minimally invasive closed reduction of acetabular both-column fractures with significant displacement remains an unresolved global challenge in orthopedic surgery. Our surgical team has developed an innovative approach that provides a novel solution to this complex clinical problem. Therefore, this article was compiled to provide a comprehensive description of this surgical technique, thereby offering novel insights for the orthopedic surgeons.

CASE PRESENTATION

A 33-year-old male patient sustained a left-sided acetabular both-column fracture due to a high-altitude fall. Under the guidance of the TiRobot ForcePro Superior, we first established a bony channel, then passed a suture-button plate through the quadrilateral plate of the acetabulum. Subsequently, high-strength sutures were tightened using a suture tensioner to achieve compression reduction of the fracture fragments. Following reduction, screws were inserted with robotic assistance via the TiRobot ForcePro Superior to achieve rigid fixation of the fracture site. The patient underwent an 11-month follow-up. Radiographic evidence of bony consolidation was confirmed at the 4th postoperative month, with no traumatic arthritis observed throughout the follow-up period. Pelvic function demonstrated excellent recovery, achieving a Majeed Pelvic Function Score of 92 points. There was virtually no difference in the patient's function regarding sitting, walking, standing, and sexual activity compared to pre-injury, and no gait alteration was observed.

CONCLUSIONS

With the assistance of robot-aided surgery combined with suture-button plates, our surgical team successfully achieved minimally invasive closed reduction and internal fixation for an acetabular both-column fracture. This innovative surgical approach provides a novel strategy for the minimally invasive management of acetabular both-column fractures.

Accuracy in navigated percutaneous sacroiliac screw fixation: a systematic review and meta-analysis

INTRODUCTION

Percutaneous sacroiliac screw fixation of pelvic fragility fractures is increasingly being used to maintain mobility and reduce pain in the elderly patient population. Traditionally, this is performed using 2D fluoroscopy. Several newer, navigated techniques have emerged that may further facilitate this procedure. It, however, remains unclear whether there is a benefit regarding accuracy, radiation exposure and complications of these new navigation techniques when compared to the traditional 2D fluoroscopy.

METHODS

A systematic review and meta-analysis were performed. PubMed, CENTRAL and Embase were searched for both randomized controlled trials and observational studies comparing new navigation techniques to 2D fluoroscopy for percutaneous sacroiliac screw fixation. Effect estimates were pooled (random effects) and presented as odds ratio, mean difference and standardized mean difference with a 95% confidence interval.

RESULTS

19 studies were included. The 2D fluoroscopy group had 642 patients and the new navigation group 663 patients. Accuracy was significantly higher in the new navigation group (OR 2.44, 95% CI 1.53-3.90), especially O-Arm, 3D CT and Robotic navigation. On average, accuracy was 82% in the 2D group and 92% in the new navigation group, which was significant. Also, fluoroscopy time (MD 71.89 s, 95% CI 51.37-92.41) and frequency (MD 17.22 images in total, 95% CI 7.73-26.70) were significantly reduced in the new navigation group. Complications are acceptably low, however, poorly reported in both groups.

CONCLUSION

This meta-analysis demonstrated a higher accuracy, lower fluoroscopic frequency and time for new navigation techniques compared to 2D fluoroscopy. More advanced navigation techniques, such as 3D CT and robotic navigation, appeared to be even better.

Iatrogenic nerve injury following pelvic ring injury: a network meta-analysis

BACKGROUND

Pelvic ring injuries are common in multi-trauma patients and can be life-threatening, necessitating prompt surgical intervention to improve outcomes. However, surgery can lead to complications such as iatrogenic nerve injury. This network meta-analysis aimed to improve outcomes in multi-trauma patients with pelvic ring injuries by evaluating the incidence of iatrogenic nerve injuries, identifying vulnerable nerves, and comparing different fixation methods.

MATERIALS AND METHODS

A systematic search of MEDLINE, EMBASE, and Scopus from inception to 5 December 2023 revealed 29 comparative studies on the incidence of iatrogenic nerve injury in 1561 adult patients with pelvic ring injuries. Data were extracted on study and patient characteristics, iatrogenic nerve injury incidences, and specific nerve injuries. A random-effects model assessed treatment effects, with subgroup analysis and meta-regression. The main outcomes included odds ratios (ORs) and confidence intervals (CIs) for iatrogenic nerve injuries.

RESULTS

Compared with closed reduction internal fixation, robotic-assisted techniques had the highest, and open reduction internal fixation had the lowest ORs for iatrogenic nerve injuries. The robotic-assisted approach ranked best with an OR of 0.22 (95% CI: 0.02-2.16), while closed reduction internal fixation with the anterior approach (OR: 0.71; 95% CI: 0.21-2.48) and open reduction internal fixation with the anterior approach performed the worst. The lateral femoral cutaneous nerve was injured in all open reduction internal fixation with anterior approach procedures and in 66.7% of open reduction internal fixation with posterior approach procedures. Meta-regression showed a significantly lower OR for iatrogenic nerve injuries in patients aged >41.4 years in the open reduction internal fixation with the anterior approach group (OR: 0.02; 95% CI: 0.001-0.63; P  = 0.026) compared with younger patients.

CONCLUSION

The robotic-assisted technique may result in the fewest iatrogenic nerve injuries during the treatment of pelvic ring injuries. The posterior approach may also reduce the risk of iatrogenic nerve injuries.

Safety and clinical efficacy of modified tracer fixation technique in orthopedic robot-assisted percutaneous vertebroplasty for Kümmell's disease

The rising incidence of osteoporotic vertebral compression fractures (OVCF) has increased the demand for precise treatments like robot-assisted percutaneous vertebroplasty (PVP), especially for conditions like Kümmell's disease that require high surgical accuracy. However, the traditional tracer fixation method has certain limitations. This study aimed to compare the safety and clinical efficacy of a modified tracer fixation technique with the traditional fixation method in robot-assisted percutaneous vertebroplasty (PVP) for Kümmell's disease. A retrospective analysis was conducted on 88 patients treated between April 2023 and January 2024. The patients were divided into two groups based on the tracer fixation method: the modified group (skin-fixed, 47 cases) and the traditional group (spinous process-fixed, 41 cases). Outcomes were measured by VAS, ODI, Cobb angle, working channel establishment time, surgical duration, intraoperative blood loss, intraoperative fluoroscopy dose, and complication rates. Both groups showed significant improvements in VAS, ODI, and Cobb angle at postoperative days 2 and 6 months (P < 0.05). The modified group had significantly lower VAS and ODI scores on postoperative days 2, shorter working channel establishment and surgical duration, and less intraoperative blood loss (P < 0.05). However, no significant differences were found in intraoperative fluoroscopy dose or complication rates (P > 0.05). In conclusion, while both techniques are safe and effective, the modified skin-fixed tracer technique offers advantages in reducing surgical trauma, significantly shortening the surgical duration, decreasing intraoperative blood loss, and promoting early recovery.

Intraoperative computerised tomography scan for percutaneous fixation of the pelvis: a retrospective case series

PURPOSE

Fractures and dislocations of the pelvic ring are complex injuries that when treating require meticulous attention to detail and often specialized technical skill. These injuries can be the result of high-energy trauma, particularly in younger patients, or low energy trauma more often found in the elderly. Regardless of mechanism, these injuries lie on a spectrum of severity and can be treated conservatively or surgically. Percutaneous fixation under fluoroscopic guidance is the preferred standard technique when treating these fractures. This technique can be challenging for a variety of reasons including patient characteristics, intra-operative image quality, fracture morphology, among others.

METHODS

This retrospective study evaluated the use of intra-operative computed tomography (CT) using an O-arm imaging system for critical evaluation of fluoroscopic-guided screw placement in twenty-three patients. We retrospectively reviewed all cases of patients who were treated by three fellowship-trained orthopaedic traumatologists during a one-year span. Patients undergoing percutaneous pelvis fixation using both standard fluoroscopy and intraoperative CT with the Medtronic O-arm® (Minneapolis, MN) imaging system. Additionally, procedures performed included open reduction internal fixation (ORIF) of the pelvic ring, acetabulum, and associated extremity fractures.

RESULTS

Twenty-three patients were included in this study. On average, the use of intraoperative CT added 24.4 min in operative time. Five patients (21.7%) required implant adjustment after O-arm spin. Fourteen patients underwent additional post-operative CT. No secondary revision surgeries were attempted after any post-operative CT.

CONCLUSIONS

Our study suggests that intra-operative CT scan, compared to post-operative CT scan, can be utilized to prevent take-back surgery for misplaced implants and allow for adjustment in real-time.

[Treatment of thoracolumbar tuberculosis with robot-assisted and minimally invasive access via transforaminal expansion approach]

Objective

To investigate the feasibility and effectiveness of robot-assisted posterior minimally invasive access in treatment of thoracolumbar tuberculosis via transforaminal expansion approach.

Methods

A clinical data of 40 patients with thoracolumbar tuberculosis admitted between January 2017 and May 2022 and met the selection criteria was retrospectively analyzed. Among them, 15 cases were treated with robot-assisted and minimally invasive access via transforaminal expansion approach for lesion removal, bone graft, and internal fixation (robotic group), and 25 cases were treated with traditional transforaminal posterior approach for lesion removal and intervertebral bone grafting (traditional group). There was no significant difference in the baseline data between the two groups ( P>0.05) in terms of gender, age, lesion segment, and preoperative American Spinal Injury Association (ASIA) grading, Cobb angle, visual analogue scale (VAS) score, erythrocyte sedimentation rate (ESR), and C reactive protein (CRP). The outcome indicators were recorded and compared between the two groups, including operation time, intraoperative bleeding volume, hospital stay, postoperative bedtime, complications, ESR and CRP before operation and at 1 week after operation, the level of serum albumin at 3 days after operation, VAS score and ASIA grading of neurological function before operation and at 6 months after operation, the implant fusion, fusion time, Cobb angle of the lesion, and the loss of Cobb angle observed by X-ray films and CT. The differences of ESR, CRP, and VAS score (change values) between pre- and post-operation were calculated and compared.

Results

Compared with the traditional group, the operation time and intraoperative bleeding volume in the robotic group were significantly lower and the serum albumin level at 3 days after operation was significantly higher ( P<0.05); the postoperative bedtime and the length of hospital stay were also shorter, but the difference was not significant ( P>0.05). There were 2 cases of poor incision healing in the traditional group, but no complication occurred in the robotic group, and the difference in the incidence of complication between the two groups was not significant ( P>0.05). There were significant differences in the change values of ESR and CRP between the two groups ( P<0.05). All Patients were followed up, and the follow-up time was 12-18 months (mean, 13.0 months) in the traditional group and 12-16 months (mean, 13.0 months) in the robotic group. Imaging review showed that all bone grafts fused, and the difference in fusion time between the two groups was not significant ( P>0.05). The difference in Cobb angle between the pre- and post-operation in the two groups was significant ( P<0.05); and the Cobb angle loss was significant more in the traditional group than in the robotic group ( P<0.05). The VAS scores of the two groups significantly decreased at 6 months after operation when compared with those before operation ( P<0.05); the difference in the change values of VAS scores between the two groups was not significant ( P>0.05). There was no occurrence or aggravation of spinal cord neurological impairment in the two groups after operation. There was a significant difference in ASIA grading between the two groups at 6 months after operation compared to that before operation ( P<0.05), while there was no significant difference between the two groups ( P>0.05).

Conclusion

Compared with traditional posterior open operation, the use of robot-assisted minimally invasive access via transforaminal approach for lesion removal and bone grafting internal fixation in the treatment of thoracolumbar tuberculosis can reduce the operation time and intraoperative bleeding, minimizes surgical trauma, and obtain definite effectiveness.

TiRobot-Assisted Percutaneous Cannulated Screw Fixation for Elderly Patients with Fragility Fractures of the Pelvis: A Retrospective Study

OBJECTIVE

The incidence of fragility fractures of the pelvis (FFPs) is increasing in the elderly population, and FFPs that require fixation are a challenge for orthopedic surgeons. The insertion of implants is not risk free due to the complex anatomical and osteoporotic bones and requires a steep learning curve. This study aimed to investigate the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of elderly FFP patients.

METHOD

The clinical data of 46 elderly FFP patients who had been treated with percutaneous cannulated screw fixation from May 2020 to September 2022 were retrospectively analyzed. Twenty-four patients were treated with percutaneous cannulated screw fixation assisted by the TiRobot (TiRobot-assisted group) and 22 patients were treated with conventional freehand surgery (freehand group). Postoperative outcomes, including Matta value, excellent and good rate (EGR) of fracture reduction, and accuracy of screw placement (ASP), were compared. Changes in the Visual analog scale (VAS) pain score and the Majeed score were recorded and compared between groups before and after surgery and during the 24-week follow-up. Repeated-measures analysis of variance (ANOVA) and effect sizes were used as analysis methods.

RESULTS

A total of 90 screws were implanted, 51 screws in the TiRobot-assisted group and 39 screws in the freehand group. The operation time of the two groups was 34.1 ± 2.67 min versus 64.5 ± 4.19 min (p < 0.001). There were no screw-related complications or revision surgeries in any group. The Matta value of the TiRobot-assisted group was 5.13 ± 3.52, which was significantly lower than that of the freehand group (9.00 ± 3.68, p < 0.001), while the EGR was 91.67% versus 72.73%, with statistical significance (p < 0.001). The ASP was 100% in the TiRobot-assisted group, better than that in the freehand group, where it was 85.7% (p = 0.043). At each timepoint in the early postoperative period, the VAS score of the TiRobot-assisted group was significantly lower than that of the freehand group and was close to consistent by the last follow-up; the Majeed score of the former was significantly higher than that of the latter at each timepoint of follow-up, with statistical significance (p < 0.001).

CONCLUSION

TiRobot-assisted percutaneous cannulated screw fixation of elderly FFP patients is advantageous over conventional freehand surgery, with less invasion, more accurate screw placement, better fracture reduction, early pain relief, and rapid recovery, suggesting that Freehand method to stabilize FFP in the elderly population.

[Application and research progress of artificial intelligence technology in trauma treatment]

Objective

To review the application and research progress of artificial intelligence (AI) technology in trauma treatment.

Methods

The recent research literature on the application of AI and related technologies in trauma treatment was reviewed and summarized in terms of prehospital assistance, in-hospital emergency care, and post-traumatic stress disorder risk regression prediction, meanwhile, the development trend of AI technology in trauma treatment were outlooked.

Results

The AI technology can rapidly analyze and manage large amount of clinical data to help doctors identify patients' situation of trauma and predict the risk of possible complications more accurately. The application of AI technology in surgical assistance and robotic operations can achieve precise surgical plan and treatment, reduce surgical risks, and shorten the operation time, so as to improve the efficiency and long-term effectiveness of the trauma treatment.

Conclusion

There is a promising future for the application of AI technology in the trauma treatment. However, it is still in the stage of exploration and development, and there are many difficulties of historical data bias, application condition limitations, as well as ethical and moral issues need to be solved.

The Use of a Robotic Arm for Fixation of Pelvic Fractures

OBJECTIVES

The objective of this study was to evaluate unplanned cortical or neuroforaminal violation of iliosacral and transsacral screw placement using fluoroscopy versus screw placement using a robotic arm.

DESIGN

This is a prospective cohort study.

SETTING

Single surgeon, single North American level 1 trauma center.

PATIENTS

Radiographic and clinical data for 21 consecutive adult trauma patients with pelvic ring fractures undergoing surgical treatment were prospectively collected. Treatment consisted of iliosacral and/or transsacral screws with or without anterior fixation.

INTERVENTION

Ten patients were treated with the assistance of a robotic arm. Eleven patients were treated with standard fluoroscopic techniques.

MAIN OUTCOME MEASUREMENTS

Thirty-two screws were placed and evaluated with postoperative computed tomography or O-arm spins to assess unplanned cortical or neuroforaminal violation. Violations were graded according to the Gertzbein and Robbins system for pedicle screw violation, categorizing screw violation in 2-mm increments. The postoperative images were blindly reviewed by 5 fellowship-trained orthopaedic traumatologists. The treating surgeon was excluded from review.

RESULTS

The Mann-Whitney U test on the Gertzbein and Robbins system results demonstrated significantly (P = 0.02) fewer violations with robotic assistance. χ2 analysis of whether there was a cortical violation of any distance demonstrated significantly (P = 0.003) fewer cortical violations with robotic assistance. There were no neurovascular injuries in either group.

CONCLUSION

Robotic assistance demonstrated significantly fewer unplanned cortical or neuroforaminal violations. Further research is needed with additional surgeons and sites to evaluate the accuracy of iliosacral and transsacral screw placement with robotic assistance.

LEVEL OF EVIDENCE

Therapeutic, level II.

[Early effectiveness of computer navigation system-assisted transiliac-transsacral screws placement for posterior pelvic ring injuries]

Objective

To investigate the early effectiveness of transiliac-transsacral screws internal fixation assisted by augmented reality navigation system HoloSight (hereinafter referred to as "computer navigation system") in the treatment of posterior pelvic ring injuries.

Methods

A retrospective analysis was made in the 41 patients with posterior pelvic ring injuries who had been treated surgically with transiliac-transsacral screws between June 2022 and June 2023. The patients were divided into navigation group (18 cases, using computer navigation system to assist screw implantation) and freehand group (23 cases, using C-arm X-ray fluoroscopy to guide screw implantation) according to the different methods of transiliac-transsacral screws placement. There was no significant difference in gender, age, body mass index, causes of injuries, Tile classification of pelvic fracture, days from injury to operation, usage of unlocking closed reduction technique between the two groups ( P>0.05). The time of screw implantation, the fluoroscopy times, the guide wire adjustment times of each screw, and the incidence of complications were recorded and compared between the two groups. The position of the transiliac-transsacral screw was scanned by CT within 2 days after operation, and the position of the screw was classified according to Gras standard.

Results

The operation was successfully completed in both groups. The time of screw implantation, the fluoroscopy times, and the guide wire adjustment times of each screw in the navigation group were significantly less than those in the freehand group ( P<0.05). There were 2 cases of incision infection in the freehand group, and the incision healed by first intention after active dressing change; there was no screw-related complication in the navigation group during operation and early period after operation; the difference in incidence of complications between the two groups (8.7% vs. 0) was not significant ( P=0.495). According to the Gras standard, the screw position of the navigation group was significantly better than that of the freehand group ( P<0.05).

Conclusion

Compared with the traditional freehand method, the computer navigation system assisted transiliac-transsacral screws internal fixation in the treatment of posterior pelvic ring injuries has advantages of improving the accuracy of screw implantation and reducing radiation damage and the time of screw implantation.