Comparison of 3D-navigation and fluoroscopic guidance in percutaneous pedicle screw placement for traumatic fractures of the thoracolumbar junction.

Introduction: Fractures of the thoracolumbar junction are the most common vertebral fractures and can require surgical treatment. Several studies have shown that the accuracy of pedicle screw placement can be improved by the use of 3D-navigation. Still only few studies have focused on the use of navigation in traumatic spine injuries. Research question: The aim of this study was to compare the screw placement accuracy and radiation exposure for 3D-navigated and fluoroscopy-guided percutaneous pedicle screw placement in traumatic fractures of the thoracolumbar junction. Materials and methods: In this single-center study 25 patients undergoing 3D-navigated percutaneous pedicle screw placement for traumatic fractures of the thoracolumbar junction (T12-L2) were compared to a control group of 25 patients using fluoroscopy. Screw accuracy was determined in postoperative CT-scans using the Gertzbein-Robbins classification system. Additionally, duration of surgery, dose area product, fluoroscopy time and intraoperative complications were compared between the groups. Results: The accuracy of 3D-navigated percutaneous pedicle screw placement was 92.66 % while an accuracy of 88.08 % was achieved using standard fluoroscopy (p = 0.19). The fluoroscopy time was significantly less in the navigation group compared to the control group (p = 0.0002). There were no significant differences in radiation exposure, duration of surgery or intraoperative complications between the groups. Discussion and conclusion: The results suggest that 3D-navigation facilitates higher accuracy in percutaneous pedicle screw placement of traumatic fractures of the thoracolumbar junction, although limitations should be considered. In this study 3D-navigation did not increase fluoroscopy time, while radiation exposure and surgery time were comparable.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

BACKGROUND: For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. METHODS: In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. RESULTS: The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). CONCLUSION: In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Does the Interval Slide Procedure Reduce Supraspinatus Tendon Repair Tension?: A Biomechanical Cadaveric Study.

BACKGROUND: The benefits of the interval slide (IS) procedure in retracted rotator cuff tears remain controversial. PURPOSE: The purpose was to evaluate the effect of the IS procedure on repair tension (RT). It was hypothesized that the IS procedure (anterior IS [AIS], posterior IS [PIS], and intra-articular capsular release [CR]) would reduce the RT of a supraspinatus tendon. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 31 Thiel-embalmed human cadaveric shoulders (mean age, 74 years; range, 68-84 years) were tested. Full-thickness supraspinatus tendon tears were created, and 1 cm of tendon was resected to simulate a retracted defect. Shoulders were randomized into intervention (n = 16) and control (n = 15) groups. In all shoulders, the load during tendon reduction to footprint was measured, an endpoint was defined as maximum tendon lateralization before 50 N was reached, and the RT (load during lateralization to endpoint) of the native tendon (t1) was evaluated. In the intervention group, AIS (t2), PIS (t3), and CR (t4) were performed in order, with RT measurement after each step. In the control group, RT was assessed at the same time points without the intervention. RESULTS: A complete reduction of the tendon was not achieved in any of the shoulders. Mean maximum lateralization was 6.7 ± 1.30 mm, with no significant differences between groups. In the intervention group, the overall IS procedure reduced RT about 47.0% (t1 vs t4: 38.7 ± 3.9 vs 20.5 ± 12.3 N; P < .001). AIS reduced RT significantly (t1 vs t2: 38.7 ± 3.9 vs 27.4 ± 10.5 N; P < .001), whereas subsequent PIS (t2 vs t3: 27.4 ± 10.5 vs 23.2 ± 12.4 N; P = .27) and CR (t3 vs t4: 23.2 ± 12.4 vs 20.5 ± 12.3 N; P = .655) did not additionally reduce tension. Comparison between groups at t4 revealed a reduction of RT of about 47.8% (control vs intervention: 39.3 ± 4.0 vs 20.5 ± 12.3 N; P < .001). CONCLUSION: The IS procedure reduces RT of the supraspinatus tendon in human cadaveric shoulders. However, performing PIS and CR subsequent to AIS does not reduce tension additionally. CLINICAL RELEVANCE: These findings provide surgeons with a biomechanical rationale regarding the efficacy of the IS procedure.

Biomechanical analysis of the interval slide procedure: a fresh porcine cadaver study.

INTRODUCTION: The interval slide procedure (IS) has been introduced to improve mobility in massive, retracted rotator cuff tears. As clinical studies showed controversial results, the benefit of the IS is still widely discussed. AIM: Aim of this study was to analyze the effect of IS procedure on tendon mobility in a fresh porcine cadaver model. MATERIALS AND METHODS: In 30 fresh porcine cadaver shoulders with artificial supraspinatus defect tendon mobility was tested by measuring the load (in N) during tendon reduction to the footprint at the greater tubercle using a sensor enhanced arthroscopic grasper (t1). In intervention group (N = 15) anterior IS (t2), posterior IS (t3) and intraarticular capsule release (t4) were successively performed, each followed by tendon mobility assessment. Tendon mobility of the control group (N = 15) was measured in same time schedule without intervention. RESULTS: Mobility did not differ between groups for native tendons (CG 28.0 ± 11.2 N vs. IG 26.6 ± 11.6 N; P = 0.75). IS procedure significantly improves mobility at about 25.2% (t1 26.6 ± 11.6 N vs. t4 19.9 ± 12.3 N; P < 0.001) compared to the native tendon and 34.1% compared to CG (CG 30.2 ± 13.7 N vs. 19.9 ± 12.3 N; P = 0.026). In posthoc analyzes, anterior IS (P < 0.001) and capsule release (P = 0.005) significantly increased mobility, whereas the posterior IS did not (P = 0.778). CONCLUSION: The IS procedure results in increased supraspinatus tendon mobility in fresh porcine cadaver shoulders. However, performing the posterior IS subsequent to the anterior IS no significant improvement of mobility has been observed.

Thermomechanical Combination Injuries: A Rare But Life-Threatening Entity.

Thermomechanical combination injuries (TMCIs) are feared for their demanding preclinical and clinical management and bear the risk of high mortality compared to the single injury of a severe burn or multiple trauma. There remains a significant lack of standardized algorithms for diagnostics and therapy of this rare entity. The objective of the present study was to profile TMCI aiming at standardized procedures. In this study, TMCIs were extracted from our burn database of a level 1 burn and trauma center. From 2004 to 2017, all patients with TMCI were retrospectively analyzed. Further inclusion criteria were multiple trauma accompanied by burn with ≥10% TBSA. Patient and injury characteristics including injury severity score and outcome parameter were analyzed. A total of 45 patients matched the selective inclusion criteria of TMCI, comprising 4% of all burn injuries during the period. The average age was 38 years (range: 14-86), with a mean TBSA of 43% (range: 10-97%). The mean recorded temperature at admission was 34.8°C (range: 29.6-37.1) with 2215 ml volume of resuscitation fluids (range: 500-8000) administered preclinically in total. The mean injury severity score was 16. The overall mortality rate was 22%. TMCIs are rare and life-threatening events that require highly qualified management in combined level 1 trauma and burn centers to address both burn and trauma treatment. The multiple injury pattern is diverse, complicating standardized management in view of burn care-specific measures, as normothermia and restrictive volume management. The present study reveals further profiles and underlines the need for addressing TMCIs in ABLS®, ATLS®, and PHTLS® programs.

Vascular impulse technology versus elevation for the reduction of swelling of lower extremity joint fractures: results of a prospective randomized controlled study.

AIMS: Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. METHODS: A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). RESULTS: The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (ppreop = 0.05; pdischarge < 0.001) and need for narcotics (ppreop = 0.064; ppostop = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. CONCLUSION: Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746-754.

Mobility Assessment of the Supraspinatus in a Porcine Cadaver Model Using a Sensor-Enhanced, Arthroscopic Grasper.

Tendon mobility is highly relevant in rotator cuff surgery. Objective data about rotator cuff mobility is rare. Tendon mobility still needs to be evaluated subjectively by the surgeon. This study aims to establish a porcine animal model for mobility analysis of the supraspinatus. In this context, we introduce a sensor-enhanced, arthroscopic grasper (SEAG) suitable for objective intraoperative measurements of tendon mobility in clinical praxis. Tendon mobility of 15 fresh porcine cadaver shoulders with artificial rotator cuff tears was evaluated using the SEAG. Mobility characteristics (load-displacement curves, maximum load, stiffness) were studied and inter- and intraobserver agreement (intraclass correlation coefficient (ICC)) were tested. Factors with a potential adverse effect (plastic deformation and rigor mortis) were also evaluated. All shoulders showed characteristic reproducible load-displacement curves with a nonlinear part at the start, followed by a linear part. Mean maximum load was 28.6 N ± 12.5. Mean stiffness was 6.0 N/mm ± 2.6. We found substantial interobserver agreement (ICC 0.672) and nearly perfect intraobserver agreement (0.944) for maximum load measurement. Inter- (0.021) and intraobserver (0.774) agreement for stiffness was lower. Plastic deformation and rigor mortis were excluded. The animal model demonstrates reliable and in vivo-like measurements of tendon mobility. The SEAG is a reliable tool for tendon mobility assessment.

Minimally invasive surgical treatment of minimally displaced acetabular fractures does not improve pain, mobility or quality of life compared to conservative treatment: a matched-pair analysis of 50 patients.

BACKGROUND: Currently available procedures for the treatment of minimally displaced acetabular fractures include conservative treatment and minimally invasive percutaneous screw fixation. Screw fixation of acetabular fractures allows patients' early full-weight bearing due to improved biomechanic stability. Can the range of motion, pain and mobility and quality of life in patients with acetabular fractures be improved by minimally invasive screw fixation, compared to conservative treatment in the long term? METHODS: Patients treated for a minimally displaced acetabular fracture, either conservatively or by closed reduction percutaneous screw fixation, in the period from 2001 to 2013 were included in this retrospective study. Minimal displacement was considered to be less than 5 mm. As well as the collection and analysis of baseline data, Harris Hip Score, Merle d'Aubigné score and Short Form 12 (SF-12) questionnaire data were recorded in the context of a clinical study. To better account for confounding factors, patients of each group were matched. The matched-pair criteria included age, BMI, Letournel fracture classification and the presence of associated injuries. RESULTS: Twenty-five patients from each group were matched. On the Harris Hip Score, conservatively treated patients obtained 96 points (52-100, SD 17) vs. 89 points (45-100, SD 17, p = 0.624). On the Merle d'Aubigné score, conservatively treated patients obtained 17 points (10-18, SD 2) vs. 17 points (11-18, SD 2, p = 0.342). Patients with acetabular fractures treated by minimally invasive screw fixation did not result in improved quality of life, measured by SF-12 questionnaire, compared to conservatively treated patients (PCS 47, SD 9 vs. 44, SD 10; p = 0.294 and MCS 51, SD 7 vs. 53, SD 7; p = 0.795). CONCLUSIONS: The clinical results of the two groups revealed no statistically significant differences. From the data, it cannot be deduced that minimally invasive surgical therapy is superior to conservative treatment of minimally displaced acetabular fractures. Prospective randomised studies are recommended to allow reliable evaluation of both treatment options. TRIAL REGISTRATION: Retrospectively registered.

Return to work after acromioclavicular joint stabilization: a retrospective case control study.

BACKGROUND: Considering the epidemiology of acromioclavicular (AC) dislocation related to young and active patients, the impact on working capacity is highly relevant. The purpose of this study was to determine the capacity of work and time to return to work (RTW) after AC joint stabilization. We hypothesized that manual working patients show more restrictions returning to work. METHODS: In this retrospective case series, pre- and posttraumatic working capacity of 54 patients (FU-rate 80.1%, FU time 23, range 18-45 month) stabilized in single TightRope technique was analyzed. Clinical outcome (DASH, Constant-Murley score) and complications were evaluated in addition. RESULTS: Fifty one of 54 patients (94.5%) were returned to work at final follow-up. The median time to return was 13 (5-143) weeks. Manual working patients showed lower RTW-rates (91.2% vs. 100%; p = .151), longer RTW-time (15.5 vs. 6 weeks; p = .008), and more often persistent shoulder symptoms at work (55.9% vs. 5%; p < .001). CONCLUSION: After stabilization of AC joint dislocation, the majority of patients returned to work, needing substantial time to return. Manual working patients required more time and often suffer under persistent symptoms at work.

Outcome of Early and Late Diagnosed Essex-Lopresti Injury.

BACKGROUND: The aim of this study was to investigate the outcomes in a large series of Essex-Lopresti injuries (ELIs) and to compare patients with early and late diagnoses. METHODS: Thirty-one patients with an ELI (average age and standard deviation [SD], 46 ± 10 years) who were followed for a minimum of 2 years were included in the study. Patients were grouped according to whether the ELI had been diagnosed early (on the day of the injury) or late (>4 weeks after the radial head injury). Acute treatment of early-diagnosed ELI included temporary stabilization of the distal radioulnar joint (DRUJ) by Kirschner wires with the forearm in supination for 6 weeks. Clinical outcomes were assessed on the basis of the range of motion, Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), visual analog scale (VAS) score for wrist and elbow pain, and Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: The ELI was diagnosed on the day of the injury in 16 patients (52%; the early group) and late (at a mean of 7 ± 7 months; range, 1 to 24 months) in 15 (48%; the late group). After a mean duration of follow-up of 5.3 ± 3.0 years (range, 2.0 to 13.1 years), patients with an early diagnosed ELI had significantly better clinical outcomes, compared with those with a late diagnosis, with regard to the MEPS (91.3 ± 8.7 versus 74.7 ± 15.3, p = 0.003), MWS (81.3 ± 16.5 versus 66.3 ± 17.6, p = 0.019), DASH score (12.5 ± 8.7 versus 45.3 ± 23.5, p = 0.001), VAS elbow pain score (0.7 ± 1.1 versus 3.3 ± 2.1, p = 0.001), and VAS wrist pain score (0.9 ± 1.2 versus 3.9 ± 1.7, p < 0.001). The ranges of motion of the elbow and wrist did not differ significantly between the early and late groups (p > 0.05). A significantly lower percentage of patients had complications or subsequent surgical procedures in the early than in the late group (38% [6 of 16] versus 93% [14 of 15], p < 0.001). CONCLUSIONS: Early diagnosis of an ELI with temporary stabilization of the DRUJ leads to satisfactory clinical mid-term results, whereas late diagnosis of an ELI is associated with a deteriorated outcome. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sports activity after anatomic acromioclavicular joint stabilisation with flip-button technique.

PURPOSE: Sports activity after surgical AC joint stabilisation has not been comprehensively evaluated to date. The aim of this study was to determine rate, level and time to return to sports after AC joint stabilisation and to identify the influence of overhead sports on post-operative sports activity. METHODS: In this retrospective case series, a total of 68 patients with a high-grade AC joint dislocation (Rockwood type V) were stabilised using a single TightRope technique. Fifty-five patients (80.9 %) with median age of 42.0 (range, 18-65) years completed questionnaires regarding sports activity before and after surgery. Clinical outcome and complications were also evaluated. Forty-three patients participated in sports regularly before injury. Their sports activity was rated according to Allain, and non-overhead and overhead sports were differentiated. RESULTS: At median follow-up of 24 (18-45) months, 41 of 43 patients (95.3 %) had returned to sports. 63 % returned to the same sports activity as before injury. 16.3 % needed to adapt the type of sports to reduce demanding activities. 11.6 % reduced the frequency and 32.5 % the intensity of sports. The median time to return to sports was 9.5 (3-18) months. Overhead athletes (Allain Type III and IV) had to reduce their sports activity significantly more often (11.8 vs. 53.8 %; p = 0.011) and needed more time to return to sports (9.5 vs. 4.5 months; p = 0.009). CONCLUSION: After stabilisation of AC joint dislocation, the majority of patients returned to sports after a substantial period of time. Overhead athletes, in particular, required more time and had to considerably reduce their sports activity. The findings impact therapeutic decision-making after AC joint injury and help with the prognosis and assessment of rehabilitation progress. LEVEL OF EVIDENCE: IV.

Additional bone graft accelerates healing of clavicle non-unions and improves long-term results after 8.9 years: a retrospective study.

BACKGROUND: Clavicle non-unions can occur after both conservative and operative treatment failure. Here, we investigated the outcome of patients with delayed fracture healing or non-unions of the clavicle. Patients underwent revision surgery by plate osteosynthesis of the clavicle with or without bone grafting. Our aim was to determine rates of bone healing and the functional long-term outcome. METHODS: The study population of 58 consecutive patients was divided into group 1 (n = 25; no bone graft) and group 2 (n = 33; iliac crest bone graft). Bone consolidation was determined by the Lane-Sandhu score preoperatively and after 2.2 ± 1.8 years, respectively. The functional long-term outcome was determined after 8.9 ± 2.7 years in all available patients (n = 30) by the Constant score, DASH (Disabilities of the Arm, Shoulder and Hand) score and SF-36, and clavicle length was measured by ultrasound as compared to the healthy side. RESULTS: Clavicle consolidation was achieved in 54 out of 58 patients (93.1%) after revision surgeries. The radiographic score and bone consolidation rates were significantly higher in group 2 (93.3%) as compared with 72% in group 1 (p = 0.02), resulting in a significantly shorter time to bone consolidation in group 2. Similarly, the relative risk for additional surgery after the first revision surgery was 4.7-fold higher in group 1 (p = 0.02). The long-term results showed overall very good results in DASH score (14.9 ± 16.5) and good results in Constant scores (77.9 ± 19.9). The group analyses found significantly better Constant scores and better visual analogue pain scale (VAS) numbers in group 2. Clavicle shortening appeared to affect the clinical results, and a mild correlation between shortening and Constant scores (R = -0.31) was found. CONCLUSIONS: This study shows high rates of bone healing and good functional outcomes after surgical revision of clavicle non-unions and further demonstrates that additional bone graft could significantly accelerate bone healing. This indicates that revision surgery of clavicle non-unions might preferably be done with additional bone graft, even if the surgeon considers that bone healing might be achieved without bone grafting.

Radial head prosthesis in complex elbow dislocations: effect of oversizing and comparison with ORIF.

PURPOSE: Elbow dislocations with complex elbow instability (CEI) and unstable radial head fractures require reconstruction by open reduction and internal fixation (ORIF) if possible or alternatively by a radial head prosthesis. The aim of this study was to determine the differential outcome of both strategies and to investigate the contribution of prosthesis-related radiographic factors such as oversizing on clinical outcome. METHODS: A total of 53 patients underwent ligament and coronoid refixation, and radial head reconstruction by ORIF (n = 18; group 1) or by monopolar modular prosthesis (n = 35; group 2). Patients were followed by the Mayo Elbow Performance Score (MEPS) and a radiological score including prosthesis oversizing, joint subluxation, ossifications, capitellar erosions, implant loosening and ulno-humeral osteoarthritis. To investigate the effect of oversizing, group 2 was subdivided by prosthesis overlenghtening ≥ 2 mm. RESULTS: A total of 42 patients (79.2%) could be followed for 3.0 ± 1.3 years with an average MEPS of 76.8 ± 17.2. Patients with ORIF had slightly better MEPS (82.1 ± 9.9) as compared with group 2 (74.7 ± 19.1) though three ORIF patients required an early conversion to prosthesis. In group 2, oversizing occurred frequently and 50% showed an overlenghtening ≥ 2 mm. Oversizing significantly decreased MEPS (63.2 ± 21.3 vs 84.7 ± 9.0; p = 0.001) and elbow range of motion and increased the occurrence of other radiological abnormalities and the risk for surgical revisions. The radiological score and prosthesis overlenghtening but not prosthesis diameter showed an inverse correlation with MEPS. CONCLUSIONS: In CEI a radial head reconstruction with a prosthesis demonstrates similarly good clinical results as compared to ORIF in anatomically sized prosthesis, but prosthesis oversizing could induce other radiographic abnormalities with then deteriorated outcome.

Posttraumatic and postoperative osteomyelitis: surgical revision strategy with persisting fistula.

INTRODUCTION: Posttraumatic and postoperative osteomyelitis (PPO) with bacteria colonisation during trauma and associated surgery is an increasing clinical problem. This study investigated the treatment of PPO by surgical revision including irrigation, debridement, and temporary hardware maintenance. In addition, a drainage was inserted as persisting fistula to control osteomyelitis until fracture healing was achieved. Trauma- and osteomyelitis-related factors that influenced the study outcome were determined. PATIENTS AND METHODS: 67 consecutive patients with PPO were included. At onset of PPO, patients had incomplete fracture healing. Patients were subdivided by time of PPO occurrence (acute, subacute or chronic), initial soft tissue trauma, anatomical location, and initial fracture type (AO classification). The study outcome measures included radiographic and clinical follow-up. RESULTS: 59 patients could be followed for an average of 23 months after revision surgery. A bone healing was achieved by 89% of patients after 14.7 ± 13.4 weeks. Fractures of the lower extremity, open fractures and comminuted C-type fractures took significantly longer to achieve bone healing (p < 0.05 each). Time of PPO occurrence did not influence bone healing. After fracture consolidation, no re-infection was found. CONCLUSIONS: This study showed high rates of bone healing, indicating that this strategy with persisting fistula should be considered as alternative treatment option in patients with PPO.

Zero-dose fluoroscopy-based close reduction and osteosynthesis of diaphyseal fracture of femurs.

This paper presents a novel technique to create a computerized fluoroscopy with zero-dose image updates for computer-assisted fluoroscopy-based close reduction and osteosynthesis of diaphyseal fracture of femurs. With the novel technique, repositioning of bone fragments during close fracture reduction will lead to image updates in each acquired imaging plane, which is equivalent to using several fluoroscopes simultaneously from different directions but without any X-ray radiation. Its application facilitates the whole fracture reduction and osteosynthesis procedure when combining with the existing leg length and antetorsion restoration methods and may result in great reduction of the X-ray radiation to the patient and to the surgical team. In this paper, we present the approach for achieving such a technique and the experimental results with plastic bones.

A fluoroscopy-based surgical navigation system for high tibial osteotomy.

High tibial osteotomy is a widely accepted treatment for unicompartmental osteoarthritis of the knee and other lower extremity deformities, particularly in young and active patients. However, it is generally recognized as a technically demanding procedure. The lack of intraoperative control of the mechanical axis of the affected limb often results in postoperative malalignments, which is one of the main reasons for poor long-term results. Moreover, inaccurate osteotomies, such as insufficient or excessive bone cut, or incorrect orientation of the chisel or saw blade, have been observed. A computer assisted intraoperative planning and navigation system is therefore proposed in order to address these technical problems. During operation, fluoroscopic images are acquired and anatomical landmarks are digitized; a patient-specific coordinate system is established accordingly. After the three-dimensional measurement of the deformity and interactive planning of the osteotomy plane, the deformity is corrected under navigational guidance. The proposed system has been successfully introduced into the clinical practice of surgery after encouraging laboratory evaluations, with results affirming that it is safe and accurate.