Application of computerized virtual preoperative planning procedures in comminuted posterior wall acetabular fractures surgery

Developing a core outcome set for acetabular fractures: a systematic review (part I)

BACKGROUND

There are indications that clinical studies investigating the surgical treatment of acetabular fractures assess different outcomes. This heterogeneity reduces the comparability of study results and, thus, limits the knowledge generated from research. Core outcome sets (COS) contain a minimum set of outcomes that should be measured in studies investigating a specific disease or injury. A COS for surgically treated acetabular fractures does not yet exist. Therefore, the aim of this study is to identify the reported outcomes in studies investigating the surgical treatment of acetabular fractures.

METHODS

Studies including skeletally mature individuals (≥ 16 years) with isolated acetabular fractures treated surgically were included. Studies with polytrauma patients, pathological fractures, additional pelvic fractures, exclusively non-surgical treatment, or juvenile individuals were excluded. Three databases and two clinical trial registries were searched on 15 November 2022. The identified outcomes were grouped and subsequently categorized according to the Core Outcome Measures in Effectiveness Trials Guidelines.

RESULTS

A total of 193 studies were included, which reported a cumulative total of 2581 outcomes. After grouping, 266 unique outcomes were identified. No outcome was examined in all studies. Pain, ability to walk independently, range of motion, quality of reduction, and heterotopic ossification were the most reported unique outcomes and assessed in at least 60% of included studies. A total of 105 outcomes were only assessed in one of the included studies. Outcomes of all five core areas and 25 outcome domains of the Core Outcome Measures in Effectiveness Trials taxonomy were examined. Furthermore, outcomes were named and defined differently, measured at different time points, and assessed using a variety of measurement instruments.

CONCLUSION

Overall, this systematic review shows that a wide range of outcomes are measured in studies examining surgical treatment of acetabular fractures. The results of this systematic review will be used in a subsequent study to develop the COS for surgically treated acetabular fractures by using the Delphi method.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022357644; COMET: 2123.

Combining 3D printing technology with customized metal plates for the treatment of complex acetabular fractures: A retrospective study

PURPOSES

The purpose of this study is to evaluate the clinical outcomes of combining 3D printing technology with customized metal plates in the treatment of complex acetabular fractures.

METHODS

A retrospective study was conducted on 42 patients with complex acetabular fractures treated at our hospital between September 1, 2020 and May 31, 2022. The patients were divided into two groups: the conventional group and the 3D printing group, with 21 individuals in each group.The conventional group underwent surgery using traditional surgical techniques, with appropriate bending and adjustment of the metal plates during the procedure. In the 3D printing group, preoperative 3D printing technology was utilized to create a physical model of the fracture, and individualized metal plates were customized based on the model after virtual reduction. Comparison was made between the two groups of patients regarding surgical approach, operative time, instrument handling time, intraoperative blood loss, number of fluoroscopy scans, fracture healing time, quality of fracture reduction postoperatively, hip joint function at 12 months postoperatively, and occurrence of complications during the follow-up period.

RESULTS

The 3D printing group showed significantly shorter surgical time (124.76±12.89 minutes vs. 174.05±12.51 minutes), instrument operation time (44.57±5.32 minutes vs. 62.9±7.47 minutes), intraoperative blood loss (337.38±51.95 mL vs. 545.24±74.39 mL), and intraoperative fluoroscopy frequency (8.25±1.18 times vs. 10.52±1.6 times) compared to the conventional group (P<0.001). The postoperative fracture reduction quality in the 3D printing group was good in 95.24% (20/21) of cases, significantly higher than the 61.90% (13/21) in the conventional group (P = 0.02). The excellent and good hip function rate in the 3D printing group was 90.48% (19/21), which was also significantly higher than 57.14% (12/21) in the conventional group (P = 0.01). No significant difference was observed between the two groups in fracture healing time (13.95±1.07 weeks vs. 13.81±1.17 weeks) and complication rate (9.52% vs. 28.57%) (P = 0.14; P = 0.24).

CONCLUSION

The application of 3D printing technology in conjunction with individualized customization of metal plates for the treatment of complex acetabular fractures can shorten surgical and instrument handling time, reduce intraoperative blood loss, and improve the quality of fracture reduction as well as the recovery of hip joint function.These results provide new insights and technical support for the treatment of complex acetabular fractures.

Computer-aided robotics for applications in fracture reduction surgery: Advances, challenges, and opportunities

The advancement of information technology and AI has boosted global economic and social development. Robot systems (RS) and computer-aided technology (CAT) are used in various domains, including social production and human existence. Traditional fracture reduction surgery relies on the expertise and surgical skills of surgeons to realign fractures in patients. Researchers have developed robotic and assisted systems to automate fracture reduction surgery in recent decades. Computer-aided fracture reduction robot system (CARS) is used to replace the manual reduction performed by conventional physicians. A partial CARS has been used successfully in clinical fracture reduction surgery. This study provides an overview of CARS. First, the RS and CAT used in fracture reduction surgery are overviewed. Furthermore, a comprehensive analysis of CARS is presented, encompassing their design, experimental validation, and clinical applications, while highlighting recent advancements and potential future directions in this domain. The suggested CARS for fracture reduction are compared in different ways. The learning curve and technical ethics of CARS are summarized. The paper addresses unresolved research gaps and technical challenges, providing recommendations to guide future study.

An End-to-End Geometry-Based Pipeline for Automatic Preoperative Surgical Planning of Pelvic Fracture Reduction and Fixation

Computer-assisted preoperative planning of pelvic fracture reduction surgery has the potential to increase the accuracy of the surgery and to reduce complications. However, the diversity of the pelvic fractures and the disturbance of small fracture fragments present a great challenge to perform reliable automatic preoperative planning. In this paper, we present a comprehensive and automatic preoperative planning pipeline for pelvic fracture surgery. It includes pelvic fracture labeling, reduction planning of the fracture, and customized screw implantation. First, automatic bone fracture labeling is performed based on the separation of the fracture sections. Then, fracture reduction planning is performed based on automatic extraction and pairing of the fracture surfaces. Finally, screw implantation is planned using the adjoint fracture surfaces. The proposed pipeline was tested on different types of pelvic fracture in 14 clinical cases. Our method achieved a translational and rotational accuracy of 2.56 mm and 3.31° in reduction planning. For fixation planning, a clinical acceptance rate of 86.7% was achieved. The results demonstrate the feasibility of the clinical application of our method. Our method has shown accuracy and reliability for complex multi-body bone fractures, which may provide effective clinical preoperative guidance and may improve the accuracy of pelvic fracture reduction surgery.

Application of a posterior anatomical integrated locking compression plate in the treatment of posterior wall acetabular fractures

BACKGROUND

Traditional fixation methods for posterior wall acetabular fractures (PWAFs) typically require the utilization of multiple plates and intraoperative plate contouring, which are technically demanding and carry the risk of intra-articular screw penetration. A novel posterior anatomical integrated locking compression plate (PAILCP) has been designed to optimize these shortcomings. This study aims to evaluate the feasibility and effectiveness of the PAILCP fixation method for the surgical management of PWAFs.

METHODS

A total of 48 patients with PWAFs who were treated surgically in our department between January 2018 and December 2022 were selected for retrospective analysis. The 48 patients were classified into groups A (PAILCP fixation, n = 25) and B (traditional fixation, n = 23) according to different fixation methods. Fracture reduction quality, number of utilized plates, blood loss, surgical time, instrumentation time, hip function, and complications were compared between the two groups.

RESULTS

A total of 25 PAILCPs were used in group A, while 34 mini-T plates and 29 reconstruction plates were employed in group B. Compared to the patients in group B, those in group A had significantly shorter instrumentation time (- 16 min) and surgical time (- 23 min) as well as lower blood loss (- 123 ml). However, no significant differences were observed in fracture reduction quality and hip function between the two groups. Additionally, the complication rate was slightly lower in group A (3/25 patients) than in group B (6/23); however, this difference was not statistically significant. Finally, follow-up examination revealed no main plate breakage, miniplate displacement, screw loosening, or intra-articular screw penetration in all patients.

CONCLUSION

The surgical treatment of PWAFs using the PAILCP fixation method results in shorter instrumentation and surgical time and lower blood loss than the traditional fixation method. Thus, the PAILCP fixation method is a promising alternative for PWAFs management, offering enhanced surgical ease and safety.

Outcomes of acetabular fractures

Acetabular fractures are prognostic relevant fractures in terms of function and daily activities. Open reduction and internal fixation (ORIF) is still the gold-standard in treating these injuries. Over recent years, several reports are dealing with outcome evaluations but have the main disadvantage of combining several fracture types., Thus, it remains unclear to discuss a fracture-based prognosis. This analysis evaluated fracture-type specific results in terms of clinical and radiological outcome. Analyzing elementary fracture types, pure transverse and isolated posterior column fractures are associated with relevant functional impairments. Except for posterior column fractures all other elementary fracture types were associated with degenerative changes in nearly 20%. Anterior column fractures seems to be "forgiving fractures" as they are associated with the longest median time until hip joint failure occurs. In associated fracture-types T-shaped fractures are still demanding fractures with < 60% anatomic reductions and a high rate of functional impairments. All associated fracture types are associated with a relevant rate of secondary degeneration of the hip joint between 20 and 40% of patients. Early hip joint failure (THR, Femoral head necrosis, severe heterotopic ossification) within the 1st year is frequently seen in associated posterior column and posterior wall fractures, but with a relative good prognosis, if the joint survived the first year after ORIF. The highest survival rates of the hip joint is observed with ABC-fractures. Also, these fractures seem to be "forgiving fractures".

Three-Dimensional Printed Plate Template Versus Hemipelvis Model in Patient-Specific Plate Preparation for Posterior Wall Acetabular Fractures

OBJECTIVE

The application of three-dimensional (3D) printing technology in the management of posterior wall acetabular fractures can greatly reduce surgical invasiveness and operative time and simplify the procedure of reconstruction plate contouring, but the cost and time of patient-specific plate preparation on the basis of traditional 3D-printed pelvis model should not be neglected. We described a new method for patient-specific plate preparation by using 3D-printed plate template. The study aimed to assess the effectiveness and feasibility of the 3D-printed plate template in patient-specific plate preparation for posterior wall acetabular fractures.

METHODS

A total of 65 cases of posterior wall acetabular fractures with surgical treatment from December 2012 to December 2020 were chosen. According to the different plate contouring methods, the 65 cases were divided into three groups, which were group A (21 cases), group B (20 cases), and group C (24 cases). In group A, the 3D-printed plate template was used to contour the patient-specific reconstruction plate before surgery, whereas the 3D-printed hemipelvis model was adopted for group B. In group C, the reconstruction plate was contoured intraoperatively. Among the three groups, the instrumentation time, surgical time, blood loss, patient-specific plate preparation time, complications, reduction quality, and hip function were compared. The Kruskal-Wallis test was used to analyze the reduction quality and hip function among three groups.

RESULTS

In comparison with group C, patients in groups A and B were featured by obviously shorter instrumentation time (-22, -23 min), shorter surgical time (-46, -44 min), and less intraoperative blood loss (-110, -122 mL). Compared to the hemipelvis model in group B (2.29 ± 0.56 vs. 12.70 ± 3.79 days), the 3D printing time for plate templates in group A was significantly shorter. The reduction quality and hip function had no obvious statistical difference among the three groups. The complication rate within group A (3/21) and group B (3/20) were both slightly lower than group C (5/24), with no obvious difference.

CONCLUSIONS

Both the patient-specific pre-contoured plate fixation methods based on the 3D-printed hemipelvis model and plate template can achieve satisfactory clinical efficacy, with the advantage of shorter instrumentation and surgical time, and less intraoperative blood loss. However, 3D printing of plate template is easier and less time-consuming, considering the shorter time and less cost for 3D printing of physical model.

Application of Virtual Reality Systems in Bone Trauma Procedures

Background and Objectives: Bone fractures contribute significantly to the global disease and disability burden and are associated with a high and escalating incidence and tremendous economic consequences. The increasingly challenging climate of orthopaedic training and practice re-echoes the established potential of leveraging computer-based reality technologies to support patient-specific simulations for procedural teaching and surgical precision. Unfortunately, despite the recognised potential of virtual reality technologies in orthopaedic surgery, its adoption and integration, particularly in fracture procedures, have lagged behind other surgical specialities. We aimed to review the available virtual reality systems adapted for orthopaedic trauma procedures. Materials and Methods: We performed an extensive literature search in Medline (PubMed), Science Direct, SpringerLink, and Google Scholar and presented a narrative synthesis of the state of the art on virtual reality systems for bone trauma procedures. Results: We categorised existing simulation modalities into those for fracture fixation techniques, drilling procedures, and prosthetic design and implantation and described the important technical features, as well as their clinical validity and applications. Conclusions: Over the past decade, an increasing number of high- and low-fidelity virtual reality systems for bone trauma procedures have been introduced, demonstrating important benefits with regard to improving procedural teaching and learning, preoperative planning and rehearsal, intraoperative precision and efficiency, and postoperative outcomes. However, further technical developments in line with industry benchmarks and metrics are needed in addition to more standardised and rigorous clinical validation.

Third-Generation Dynamic Anterior Plate-Screw System for Quadrilateral Fractures: Digital Design Based on 834 Pelvic Measurements

Background and Objectives: To investigate the digital measurement method for the plate trajectory of dynamic anterior plate-screw system for quadrilateral plate (DAPSQ), and then design a third-generation DAPSQ plate that conforms to the needs of the Chinese population through collating a large sample anatomical data. Materials and Methods: Firstly, the length of the pubic region, quadrilateral region, iliac region, and the total length of the DAPSQ trajectory were measured by a digital measurement approach in 22 complete pelvic specimens. Then, the results were compared with the direct measurement of pelvic specimens to verify the reliability of the digital measurement method. Secondly, 504 cases (834 hemilateral pelvis) of adult pelvic CT images were collected from four medical centers in China. The four DAPSQ trajectory parameters were obtained with the digital measurement method. Finally, the third-generation DAPSQ plate was designed, and its applicability was verified. Results: There was no statistically significant difference in the four trajectory parameters when comparing the direct measurement method with the digital measurement method (p > 0.05). The average lengths of the pubic region, quadrilateral region, iliac region, and the total length in Chinese population were (60.96 ± 5.39) mm, (69.11 ± 5.28) mm, (84.40 ± 6.41) mm, and (214.46 ± 10.15) mm, respectively. Based on the measurement results, six models of the DAPSQ plate including small size (A1,A2), medium size (B1,B2), and the large size (C1,C2) were designed. The verification experiment showed that all these six type plates could meet the requirement of 94.36% cases. Conclusions: A reliable computerized method for measuring irregular pelvic structure was proposed, which not only provided an anatomical basis for the design of the third-generation DAPSQ plate, but also provided a reference for the design of other pelvic fixation devices.

Computer-assisted preoperative planning of bone fracture fixation surgery: A state-of-the-art review

Background: Bone fracture fixation surgery is one of the most commonly performed surgical procedures in the orthopedic field. However, fracture healing complications occur frequently, and the choice of the most optimal surgical approach often remains challenging. In the last years, computational tools have been developed with the aim to assist preoperative planning procedures of bone fracture fixation surgery. Objectives: The aims of this review are 1) to provide a comprehensive overview of the state-of-the-art in computer-assisted preoperative planning of bone fracture fixation surgery, 2) to assess the clinical feasibility of the existing virtual planning approaches, and 3) to assess their clinical efficacy in terms of clinical outcomes as compared to conventional planning methods. Methods: A literature search was performed in the MEDLINE-PubMed, Ovid-EMBASE, Ovid-EMCARE, Web of Science, and Cochrane libraries to identify articles reporting on the clinical use of computer-assisted preoperative planning of bone fracture fixation. Results: 79 articles were included to provide an overview of the state-of-the art in virtual planning. While patient-specific geometrical model construction, virtual bone fracture reduction, and virtual fixation planning are routinely applied in virtual planning, biomechanical analysis is rarely included in the planning framework. 21 of the included studies were used to assess the feasibility and efficacy of computer-assisted planning methods. The reported total mean planning duration ranged from 22 to 258 min in different studies. Computer-assisted planning resulted in reduced operation time (Standardized Mean Difference (SMD): -2.19; 95% Confidence Interval (CI): -2.87, -1.50), less blood loss (SMD: -1.99; 95% CI: -2.75, -1.24), decreased frequency of fluoroscopy (SMD: -2.18; 95% CI: -2.74, -1.61), shortened fracture healing times (SMD: -0.51; 95% CI: -0.97, -0.05) and less postoperative complications (Risk Ratio (RR): 0.64, 95% CI: 0.46, 0.90). No significant differences were found in hospitalization duration. Some studies reported improvements in reduction quality and functional outcomes but these results were not pooled for meta-analysis, since the reported outcome measures were too heterogeneous. Conclusion: Current computer-assisted planning approaches are feasible to be used in clinical practice and have been shown to improve clinical outcomes. Including biomechanical analysis into the framework has the potential to further improve clinical outcome.

One-stop computerized virtual planning system for the surgical management of posterior wall acetabular fractures

Background

Posterior wall acetabular fractures remain one of the most difficult fracture injuries to treat. Accurate assessment of fracture characteristics and appropriate preoperative surgical strategies are essential for excellent reduction. This paper evaluates the feasibility and effectiveness of a one-stop computerized virtual planning system for the surgical management of posterior wall acetabular fractures.

Methods

52 cases of posterior wall acetabular fractures treated surgically were selected in our department between January 2015 and December 2020 for retrospective analysis. 52 cases were classified into group A (25 patients) and group B (27 patients) according to whether computerized virtual planning procedures were performed preoperatively. In group A, virtual surgical simulation was conducted using a one-stop computerized planning system preoperatively. In group B, traditional surgery was employed. Reduction quality, surgical time, blood loss, hip function, complications, and instrumentation time were compared between the two groups.

Results

The actual surgery for all patients in group A was essentially the same as the virtual surgery before the operation. Compared to group B, patients in group A had markedly shorter surgical time (−43 min), shorter instrumentation time (−20 min), and less intraoperative blood loss (−130 ml). However, no significant statistical difference was observed in reduction quality and hip function. The complication rate was slightly lower in group A (4/25) than in group B (7/27), without a significant difference.

Conclusion

The one-stop computerized virtual planning system is a highly effective, user-friendly and educational tool for allowing the cost-efficient surgical simulation of posterior wall acetabular fractures and providing a more individualized therapeutic schedule. The one-stop computerized planning system is feasible to treat posterior wall acetabular fractures, which is an effective method than the conventional treatment of posterior wall acetabular fractures.

Trial registration: retrospective registration.

Effects of Different Surgical Procedures on the Therapeutic Effects, Prognosis, and Major Complications of Acetabular Fractures in the Elderly of China: A Systematic Review and Meta-Analysis

Objective. Different surgical approaches were systematically evaluated to provide an evidence-based medical rationale for the application and promotion of acetabular fractures in the elderly of China. Methods. Randomized controlled trials (RCT) of different surgical methods in the treatment of elderly acetabular fractures were searched in the PubMed, EMBASE, ScienceDirect, Cochrane Library, China Knowledge Network Database (CNKI), China VIP Database, Wanfang Database, and China Biomedical Literature Database (CBM). The search time threshold was set from the time the database was created to the current time. Investigators obtained data independently, and the bias risk of each included writing was reviewed using the Cochrane Manual 5.1.0 criterion. The meta data was analyzed using RevMan 5.4 statistical package. Results. 6 RCT articles were included in the end. A total of 445 samples were analyzed by meta. All the six RCT literatures included in this meta-analysis reported the baseline status of patients, only 3 RCT mentioned “random assignment” without any explanation, and the rest did not mention “random” information. The five studies included all gave detailed intervention measures. The number and reasons of blind method and lost follow-up or withdrawal were not described in detail in 6 RCT articles. Through the meta-analysis excellent and good rate between the experimental group and the control group through 6 RCT studies, the heterogeneity test results were $\text{ch}{\text{i}}^2=6.11$ , $\text{df}=4$ , $\text{P}=0.19>0.05$ , and ${\text{I}}^2=35\%$ , without obvious heterogeneity at $Z=2.68$ and $P=0.007$ . These results suggested that the total hip arthroplasty application has the same excellent rate as other surgical treatment methods, indicating that total hip arthroplasty has a significant effect on the treatment of elderly acetabular fractures. Through the meta-analysis hip-joint function score, the heterogeneity test results were $\text{ch}{\text{i}}^2=56.16$ , $\text{df}=4$ , $P<0.00001$ , and $I^2=93\%$ , with obvious heterogeneity. The great difference was discovered in hip function score between total hip arthroplasty and other surgical methods, showing that total hip arthroplasty can greatly improve hip-joint function. Then, the incidence of hip complications between the experimental cases and the control cases was calculated by meta. The heterogeneity test results were $\text{ch}{\text{i}}^2=3.17$ , $\text{df}=4$ , $P=0.53>0.05$ , and $I^2=0\%$ , without remarkable heterogeneity at $Z=3.05$ and $P=0.002$ . This demonstrated that a significant difference was observed in the complication incidence, indicating that total hip arthroplasty displayed a lower incidence of hip-joint functional complications. Conclusion. Total hip arthroplasty has a good prognosis and a low complication rate in the treatment of acetabular fractures in the elderly. However, more studies and longer follow-ups are needed to further validate the findings of this study.