Use of a Hybrid Operating Room to Improve Reduction of Syndesmotic Injuries in Ankle Fractures: A Case Report

Comparison of a ceiling-mounted 3D flat panel detector vs. conventional intraoperative 2D fluoroscopy in plate osteosynthesis of distal radius fractures with volar locking plate systems

Objectives

To compare intraoperative 3D fluoroscopy with a ceiling-mounted flat panel detector in plate osteosynthesis of distal radius fractures (AO/OTA 2R3C1.2) with volar locking plate systems to conventional 2D fluoroscopy for detection of insufficient fracture reduction, plate misplacement and protruding screws.

Methods

Using a common volar approach on 12 cadaver forearms, total intraarticular distal radius fractures were induced, manually reduced and internally fixated with a 2.4 distal radius locking compression plate. 2D (anterior-posterior and lateral) and 3D (rotational) fluoroscopic images were taken as well as computed tomographies. Fluoroscopic images, Cone Beam CT (CBCT), 360° rotating sequences (so called “Movies”) and CT scans were co-evaluated by a specialist orthopedic surgeon and a specialist radiologist regarding quality of fracture reduction, position of plate, position of the three distal locking screws and position of the three diaphyseal screws. In reference to gold standard CT, sensitivity and specifity were analyzed.

Results

“Movie” showed highest sensitivity for detection of insufficient fracture reduction (88%). Sensitivity for detection of incorrect position of plate was 100% for CBCT and 90% for “Movie.” For intraarticular position of screws, 2D fluoroscopy and CBCT showed highest sensitivity and specifity (100 and 91%, respectively). Regarding detection of only marginal intraarticular position of screws, sensitivity and specifity of 2D fluoroscopy reached 100% (CBCT: 100 and 83%). “Movie” showed highest sensitivity for detection of overlapping position of screws (100%). When it comes to specifity, CBCT achieved 100%. Regarding detection of only marginal overlapping position of screws, 2D fluoroscopy and “Movie” showed highest sensitivity (100%). CBCT achieved highest specifity (100%).

Conclusion

As for assessment of quality of fracture reduction and detection of incorrect position of plate as well as overlapping position of the three diaphyseal screws CBCT and “Movie” are comparable to CT – especially when combined. Particularly sensitivity is high compared to standard 2D fluoroscopy.

Beyond the pillars of the ankle: A prospective randomized CT analysis of syndesmosis' injuries in Weber B and C type fractures

BACKGROUND

This study compared clinical and radiographic results of patients who underwent stabilization of syndesmosis with one tricortical syndesmotic screw divided into three different groups: Group A without preoperative fractured ankle computed tomography (CT) scan, Group B with preoperative fractured CT scan, and Group C with preoperative bilateral ankle CT analysis.

METHODS

Between June 2016 and May 2017, fifty-one patients with fracture type AO/OTA 44 B and C were analyzed. Of those, 14 (27.45%) were assigned to Group A, 19 (37.25%) to Group B, and 18 (35.30%) to Group C. Clinical outcomes with AOFAS score at 3, 6 and 12 months were recorded. Seven measurements on axial CT scan images were confronted between the injured and uninjured ankle to check the accuracy of reduction.

RESULTS

At three months of follow up the median AOFAS score was 70.86 ± 2.98 with no significative difference between groups (p = 0.105). At 12 months of follow up the median AOFAS score was higher in group C (93.44 ± 3.01) compared to Group B and Group C. The seven variables measured at the CT scan after syndesmotic reduction were statistically different between groups. We found a better restoration of the tibiofibular distances and the correct ankle anatomy in Group C respect to Group A and Group B.

CONCLUSIONS

Use of the pre-operative CT scan of the injured and uninjured ankle give to the surgeons the more and accurate information for the reduction and help him intraoperative in the correct maneuvers. The accuracy of the syndesmosis reduction determines better clinical outcomes.

A Multidisciplinary Approach to Treating Traumatic Pelvic Fractures: 1.1 www.aornjournal.org/content/cme

Pelvic fractures are traumatic injuries that can be caused by motor vehicle accidents, motorcycle accidents, motor vehicle-related pedestrian injuries, or falls from a significant height. These injuries can be life threatening because of the high vascularity of the pelvis and the difficulty in being able to see bleeding occurring in this area. Traditional approaches to treat pelvic fractures have been pelvic binding, external fixation, and open preperitoneal packing; however, the use of angiography and embolization enables faster pinpointing of the location of the bleeding. Increased use of hybrid ORs for treating traumatic pelvic fractures combines the superior imaging of interventional radiology with an OR that can quickly provide open interventions without needing to move a patient from an interventional radiology suite to another OR. This improvement in technology has combined the resources and knowledge of more diverse disciplines to provide a more centralized approach to improving patient outcomes.

New advances in intra-operative imaging in trauma

The invention of flat-panel detectors led to a revolution in medical imaging. The major benefits of this technology are a higher image quality and dose reduction. Flat-panel detectors have proved to be superior to standard C-arms (= C-arm with radiograph source and image intensifier).

Cone-beam computed tomography (cone-beam CT) is a 3D data set, which can be acquired with a flat-panel detector. The cone-shaped beam is used for 3D data generation. For cone-beam CT acquisition, the flat-panel detector rotates around the patient lying on the operating table. Intra-operative cone-beam CT can be a very helpful tool in orthopaedic surgery. Immediate control of fracture reduction and implant positioning in high image quality can reduce the need for secondary revision surgery due to implant malposition.

In recent years there has been a revival of standard fan beam CT technology in operating rooms. Fixed and mobile systems are available. Fixed systems are typically placed on a sliding gantry. Different mobile intra-operative CT scanners were recently introduced. Due to their mobility, they are not bound to a specific operating room. The use of standard intra-operative CT scanners results in high 3D image quality but, in comparison with a cone-beam CT scanner, fluoroscopy is not possible.

The introduction of flat-panel detectors has led to improvements in intra-operative image quality combined with dose reduction. The possibility of high-quality 3D imaging in combination with navigation can assure optimal implant placement. Due to immediate control of the osteosynthesis, revision surgery at a later time can be prevented.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170055

Current trends in the diagnosis and management of syndesmotic injury

Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today's body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.