Use of 3D Navigation Versus Traditional Fluoroscopy for Posterior Pelvic Ring Fixation

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.

Preoperative 3D printing planning technology combined with orthopedic surgical robot-assisted minimally invasive screw fixation for the treatment of pelvic fractures: a retrospective study

Objective

To explore the advantages and effectiveness of preoperative 3D printing planning technology combined with orthopedic surgical robot-assisted screw placement in the minimally invasive treatment of pelvic fractures compared to orthopedic surgical robot-assisted screw placement alone.

Methods

A retrospective analysis of the clinical data of 29 patients with unstable pelvic fractures treated with orthopedic surgical robot-assisted percutaneous screw fixation from July 2021 to August 2023 was conducted. Among them, 13 patients who underwent preoperative 3D printing technology for screw planning were assigned to the experimental group, and the remaining 16 patients were assigned to the control group. All patients underwent screw fixation alone or combined with other fixation methods for fracture fixation. The application of preoperative 3D printing planning in orthopedic surgical robot operations was described. The intraoperative screw drawing time, invasive operation time, number of fluoroscopies during invasive operation, postoperative evaluation of screw accuracy, fracture healing, complications, and functional outcomes were recorded and compared between the two groups.

Results

All patients successfully underwent surgery, with one patient in the control group experiencing numbness in the sciatic nerve innervation area. All patients were followed up for 4-15 months, with an average of 8 months, and all fractures achieved healing. The experimental group had a total of 26 screws inserted, while the control group had 30 screws. In the experimental group, the intraoperative screw drawing time was 3.0 (3.0, 3.37) min, significantly shorter than 4.0 (3.6, 4.0) min in the control group (P < 0.05). The proportion of screws not penetrating the bone postoperatively was 88.5% in the experimental group, significantly higher than 63.3% in the control group (P < 0.05). In the experimental group, the postoperative screw position, compared to the planned screw position, had an average position deviation of 3.05 ± 0.673 mm and an average spatial angle deviation of 2.22 ± 0.605°. At the last follow-up, the Majeed score was used to assess function, with the experimental group having an excellent and good rate of 84.6%, slightly higher than 75.0% in the control group, but the difference was not statistically significant (P > 0.05).

Conclusion

In the treatment of pelvic fractures using screw fixation, preoperative 3D printing technology planning combined with orthopedic surgical robots, compared to orthopedic surgical robot-assisted screw placement alone, can significantly reduce intraoperative screw drawing time, decrease drawing difficulty, enhance screw placement accuracy, and does not increase invasive operation time or the number of fluoroscopies. This approach makes the surgery safer and is a method worth applying.

FFP: Indication for minimally invasive navigation technique

An 85-year-old female patient was transferred to our clinic for surgical treatment of a complex FFP IIc. She had suffered a ground level fall 10 days ago and was still living independently. The patient was initially treated conservatively with pain medication and immobilization in an outward hospital. Due to the clinical symptoms and complex fracture pattern a physiotherapeutic assisted mobilization was not possible. The clinical examination revealed severe bilateral pain at the anterior and posterior pelvic ring. We performed a minimally invasive and an image-guided surgical stabilization. After surgical treatment the patient was mobilized with crutches for short distances. On the third day after surgical intervention the patient was discharged from our hospital into rehabilitation. This case shows the successful use of minimally invasive and modern navigation technique for treatment of a complex FFP.

Imaging, post-processing and navigation: Surgical applications in pelvic fracture treatment

Technical advancements of the past decade have led to massive improvements regarding imaging and visualization in trauma care. Digital imaging technology has fundamentally changed most processes in fracture management. However, the digital revolution in trauma surgery has just begun. Optical tracking navigation is currently the gold standard for positioning of implants for advanced applications in trauma surgery. Digital technology may enable the surgeon to achieve the same level of safety even in non-navigated placement of screws: We developed a new planning tool to transcript a preoperative into a semi-transparent "fluoroscopic like" image that can be identified intraoperatively and used as a map for the safe placement of sacro-iliac screws based on the "vestibule concept". In the future, development of artificial intelligence algorithms may provide features like automated segmentation of bone-fragments and other applications for a systematic fracture analysis to improve the standard of care in trauma surgery. Digital transformation has massive impact on diagnostics and surgical management of pelvic fractures. Improved visualization technology provides a better understanding of the surgical anatomy of the pelvis and may enable the surgeon to achieve greatest safety in percutaneous placement of screws even without using optical tracking navigation tools. The "para-axial fusion technique" is a useful tool to plan fluoroscopic views based on a 3D dataset prior to the surgery.

[Preliminary application study of dual-robotic navigated minimally invasive treatment by TiRobot and Artis Zeego on pelvic fractures]

Objective

To summarize the surgical learning curve and preliminary operative experience of dual-robotic navigated minimally invasive treatment on pelvic fractures by TiRobot and Artis Zeego.

Methods

Between July 2019 and February 2021, 90 patients with pelvic fractures were treated with dual-robotic navigated minimally invasive surgery by TiRobot and Artis Zeego. There were 64 males and 26 females, with an average age of 46.5 years (range, 13-78 years). Body mass index was 14.67-32.66 kg/m 2 (mean, 23.61 kg/m 2). Causes of injuries included traffic accident in 43 cases, falling from height in 37 cases, low-energy injuries such as flat falls in 10 cases. The interval between injury and surgery was 1-36 days (mean, 7.3 days). According to the location of the implanted screws, the patients were divided into sacroiliac screw group ( n=33), acetabular screw group (acetabulum anterior/posterior column, n=24), composite screws group (sacroiliac and acetabulum anterior/posterior column, n=33). According to the screw implantation time and accuracy, the surgical learning curve was plotted, and the differences in the relevant indicators between learning stage and skilled stage were compared.

Results

All 90 patients successfully completed the operation, the intraoperative bleeding volume was 5-200 mL (median, 20 mL). There was no vascular or nerve injury. All incisions healed by first intention. The screw implantation time ranged from 7.5 to 33.0 minutes (mean, 18.92 minutes), and the screw implantation accuracy ranged from 1.1 to 1.8 mm (mean, 1.56 mm). According to the learning curve, the practice stage of 3 groups was reached after 7, 10, and 11 cases, respectively. With the accumulation of surgical experience, the screw implantation time had a significant downward trend. Compared with the learning stage, the screw implantation time on skilled stage in 3 groups significantly shortened ( P<0.05), but the difference in the screw implantation accuracy was not significant ( P>0.05).

Conclusion

TiRobot and Artis Zeego assisted pelvic fracture surgery is safe and efficient, which helps the surgeon to quickly master the pelvic channel screw surgery, and the operation time is significantly shortened on the premise of ensuring the implantation accuracy.

Design and evaluation of an intelligent reduction robot system for the minimally invasive reduction in pelvic fractures

Introduction

Pelvic fracture is a severe high-energy injury with the highest disability and mortality of all fractures. Traditional open surgery is associated with extensive soft tissue damages and many complications. Minimally invasive surgery potentially mitigates the risks of open surgical procedures and is becoming a new standard for pelvic fracture treatment. The accurate reduction has been recognized as the cornerstone of minimally invasive surgery for pelvic fracture. At present, the closed reduction in pelvic fractures is limited by the current sub-optimal 2D intra-operative imaging (fluoroscopy) and by the high forces of soft tissue involved in the fragment manipulation, which might result in fracture malreduction. To overcome these shortcomings and facilitate pelvic fracture reduction, we developed an intelligent robot-assisted fracture reduction (RAFR) system for pelvic fracture.

Methods

The presented method is divided into three parts. The first part is the preparation of 20 pelvic fracture models. In the second part, we offer an automatic reduction algorithm of our robotic reduction system, including Intraoperative real-time 3D navigation, reduction path planning, control and fixation, and robotic-assisted fracture reduction. In the third part, image registration accuracy and fracture reduction accuracy were calculated and analyzed.

Results

All 20 pelvic fracture bone models were reduced by the RAFR system; the mean registration error E1 of the 20 models was 1.29 ± 0.57 mm. The mean reduction error E2 of the 20 models was 2.72 ± 0.82 mm. The global error analysis of registration and reduction results showed that higher errors are mainly located at the edge of the pelvis, such as the iliac wing.

Conclusion

The accuracy of image registration error and fracture reduction error in our study was excellent, which could reach the requirements of the clinical environment. Our study demonstrated the precision and effectiveness of our RAFR system and its applicability and usability in clinical practice, thus paving the way toward robot minimally invasive pelvic fracture surgeries.