Minimally invasive surgery under fluoro-navigation for anterior pelvic ring fractures.

BACKGROUND: The incidence of pelvic fractures in trauma patients is reported to be 3-8.2%, with roughly half of these fractures being caused by high energy injuries with a potential for catastrophic hemorrhage and death. Indications for internal fixation of anterior pelvic ring are controversial. Because of fears of disturbing the pelvic hematoma and causing additional hemorrhage, open reduction and internal fixation of pelvic ring disruption is routinely delayed. In contrast to conventional surgery, percutaneous screw fixation is gaining popularity in the treatment of pelvic and acetabular fractures mainly because of minimal soft tissue damage, less operative blood loss, early surgical intervention and comfortable mobilization of the patient. Fluoro-navigation is a new surgical technique in orthopedic trauma surgery. This study is to investigate clinical results of fluoro-navigation surgery in anterior pelvic ring fractures. MATERIALS AND METHODS: From January 2006 to October 2011, 23 patients with anterior pelvic ring fractures were treated with percutaneous cannulated screw under fluoro-navigation. There were 14 men and 9 women, with a mean age of 40.1 years (range 25-55). According to the AO and Orthopedic Trauma Association classification, there were seven A 2.1, two A 2.2, one A 2.3, six B 1.2, one B 2.1: 1, one B 2.2, one C 1.2, two C 1.3 and two C 2.3 types of fractures. Amongst these patients, 13 had posterior pelvic ring injuries, 8 had other injuries including urethral, lumbar vertebrae fractures and femoral fractures. All patients were operated when their general condition stabilized after emergency management. The mean time from injury to percutaneous screw fixation of the anterior pelvic ring fracture was 12 days (3-15 days). All the anterior ring fractures were fixed with cannulated screws by two senior surgeons. They were familiar with the navigation system and had gained much experience in the computer-assisted percutaneous placement of screws. RESULTS: A total of 32 screws were inserted, including 19 in the pubic ramis and 13 in the anterior acetabular columns. The average surgical time was 23.3 min/screw. The average time of X-ray exposure was 19.1 ± 2.5 s/screw. The virtual images of fluoro-navigation were compared with real-time X-rays during and after the surgery. Compared to the final position of the screw, the average deviated distance was 3.11 mm and the average trajectory difference was 2.81°. Blood loss during the operation was minimal (22.3 ml/screw). One screw (3.1%) deviated out of the fracture site during the operation. No superficial or deep infection occurred. No patient sustained recognized neurologic, vascular, or urologic injury as a result of the percutaneous screw fixation. All fractures united at the last followup. CONCLUSIONS: Fluoro-navigation technique could become a safe, accurate, and fairly quick method for the treatment of anterior pelvic ring fractures. Standardization of the operative procedure and training are mandatory for the success of this procedure.

Pathoanatomy and incidence of the posterolateral fractures in bicondylar tibial plateau fractures: a clinical computed tomography-based measurement and the associated biomechanical model simulation.

OBJECTIVES: The aim of our study is to evaluate the incidence and pathoanatomy of posterolateral fragments and analyze the associated fracture mechanism in bicondylar tibial plateau fractures. METHODS: From 1.1.2008 to 3.15.2012, all patients suffering bicondylar tibial plateau fractures were identified, scanned and analyzed at the Shanghai Clinical Trauma Center. Furthermore cadaver knees were selected into three groups of 30/60/90 knee flexion to simulate the posterolateral tibial plateau fracture by an impact device. RESULTS: One hundred and sixty-four (44.32 %) bicondylar tibial plateau fractures finally satisfied our requirements. Fifty-three and ninety-four cases were measured eventually in the groups of posterolateral split and depression. The posterolateral articular fragment proportion was 15.43 %. The posterolateral articular fragment angle showed an average of 12.94°. The posterolateral fragment cortical height was on average 2.96 cm. The posterolateral sagittal fragment angle averaged at 72.06°. Ninety-four cases were measured in the posterolateral depression group. The average posterolateral articular depression proportion was 16.74 %. The average posterolateral articular depression height was 2.47 cm. In the biomechanical modeling of such kinds of fracture patterns, posterolateral split fractures in 30° and 60° flexion are significantly more than those in 90° flexion. Posterolateral splits combined with anterolateral depression fractures in 30° flexion are significantly more than those in 90° flexion. CONCLUSION: The incidence of posterolateral fractures is 44.32 % in bicondylar tibial plateau fractures. The morphology of posterolateral area can be referenced for the surgeon in the future clinical work. The information is also helpful for the design of locking plate and fracture modeling in biomechanical test. In addition, that posterolateral split and posterolateral depression might be caused by different injury mechanisms. Different angles of knee flexion under the axial impact loading are possibly the interpretations for these two fracture patterns.

Inter-observer reliability assessment of the Schatzker, AO/OTA and three-column classification of tibial plateau fractures.

BACKGROUND: The purpose of our study was to evaluate inter-observer reliability of the Three-Column classifications with conventional Schatzker and AO/OTA of Tibial Plateau Fractures. METHODS: 50 cases involving all kinds of the fracture patterns were collected from 278 consecutive patients with tibial plateau fractures who were internal fixed in department of Orthopedics and Trauma III in Shanghai Sixth People's Hospital. The series were arranged randomly, numbered 1 to 50. Four observers were chosen to classify these cases. Before the research, a classification training session was held to each observer. They were given as much time as they required evaluating the radiographs accurately and independently. The classification choices made at the first viewing were not available during the second viewing. The observers were not provided with any feedback after the first viewing. The kappa statistic was used to analyze the inter-observer reliability of the three fracture classification made by the four observers. RESULTS: The mean kappa values for inter-observer reliability regarding Schatzker classification was 0.567 (range: 0.513-0.589), representing "moderate agreement". The mean kappa values for inter-observer reliability regarding AO/ASIF classification systems was 0.623 (range: 0.510-0.710) representing "substantial agreement". The mean kappa values for inter-observer reliability regarding Three-Column classification systems was 0.766 (range: 0.706-0.890), representing "substantial agreement". CONCLUSION: Three-Column classification, which is dependent on the understanding of the fractures using CT scans as well as the 3D reconstruction can identity the posterior column fracture or fragment. It showed "substantial agreement" in the assessment of inter-observer reliability, higher than the conventional Schatzker and AO/OTA classifications. We finally conclude that Three-Column classification provides a higher agreement among different surgeons and could be popularized and widely practiced in other clinical centers.

Computed tomography-based Three-Column Classification in tibial plateau fractures: introduction of its utility and assessment of its reproducibility.

BACKGROUND: The purpose of our study is to introduce a new Three-Column Classification for tibial plateau fractures and evaluate its reproducibility and reliability. METHODS: From December 2004 to December 2006, 278 consecutive patients with tibial plateau fractures were treated operatively at the Department of Orthopedics and Trauma III in Shanghai Sixth People's Hospital. Computed tomography (CT) and three-dimensional reconstruction were preformed for each patient before open reduction and internal fixation. The approaches were instructed by the Three-Column Classification. To test the reproducibility of the Three-Column Classification, the interobserver and intraobserver reliability of this classification system compared with that of the Schatzker Classification was investigated by four observers. RESULTS: Fourteen cases could not be classified by Schatzker Classification. Meanwhile, all cases could be classified by the Three-Column Classification. Using plain radiographs, the mean κ values for interobserver reliability using Schatzker Classification systems were 0.567 (range, 0.513-0.589), representing "moderate agreement," whereas the mean κ values were 0.766 (range, 0.706-0.890), representing "substantial agreement" by the use of the Three-Column Classification based on the CT scan. The mean κ values for intraobserver reliability using Schatzker Classification and the Three-Column Classification based on the CT scan were 0.758 (range, 0.691-0.854) and 0.810 (range, 0.745-0.918), respectively, representing "substantial agreement." CONCLUSION: The Three-Column Classification demonstrates a higher interobserver reliability and can be used as a supplement to the conventional Schatzker Classification, especially in the complex and posterior comminuted tibial plateau fractures. Furthermore, the Three-Column Classification is clinically relevant and, to some degree, can instruct the surgeon in preoperative planning. LEVEL OF EVIDENCE: Diagnostic study, level III.

Minimally invasive fluoro-navigation screw fixation for the treatment of pelvic ring injuries.

Intensive use of intraoperative fluoroscopy is mandatory to achieve good accuracy and avoid neural or vascular injury and may prolong surgical time and increase exposure-related hazards. New methods of percutaneous treatment in conjunction with innovative fluoroscopy-based computerized navigation have evolved in an attempt to overcome the existing difficulties. This report described our experience in applying fluoroscopic surgical navigation technique and evaluated its clinical application to pelvic ring injuries, including its feasibility, merits and limitations. Twenty-two patients with pelvic ring injuries were treated with percutaneous pubic ramus screw and sacroiliac screw techniques under the guidance of a fluoroscopy-based navigation system. A total of forty-four screws were inserted, including twenty-seven pubic ramus screws and seventeen sacroiliac screws. The average operation time and the average fluoroscopy time per screw were 23.6 minutes and 22.2 seconds respectively. Compared to the final position of the screw, the average deviated distance of wire tip was 2.8 mm and the average trajectory difference was 2.6°. A ventral cortex perforation of the sacrum was found in one sacroiliac screw without any clinical symptoms. No superficial or deep infection occurred. No patient sustained recognized neurologic, vascular, or urologic injury as a result of percutaneous screw fixation of pubic ramus fractures, sacroiliac disruptions, or sacral fractures. Our results showed that fluoroscopy-based navigation technique for the pelvic ring injuries could become a safe and effective alterative method for the treatment of pelvic ring injuries in some selected patients.

[Minimally invasive surgery of pelvic-acetabular fractures with fluoro-navigation].

OBJECTIVE: To investigate the clinical application of fluoro-navigation in the surgery for pelvic fractures. METHODS: A fluoro-navigation system was used to guide the placement of screws for the fixation of pelvic and acetabular fractures in 22 patients, 14 males and 8 females, aged 39.4. Totally 41 screws were inserted, 15 in pubic ramus, 13 in acetabulums, and 13 in sacroiliac joints. The images of fluoro-navigation were compared with those of the real X rays during and after surgery. RESULTS: The average time for operation was 22.7 minutes/screw, and the average time of X rays exposure was 20.2 seconds/screw. The mean deviated distance was 2.9 +/- 1.2 mm and the mean deviated angle was (2.2 +/- 0.3) degrees in the post operational verification. The blood loss during the operation was minimal (< 21.7 ml/screw). One screw (2.4%) was deviated out of the fracture during the operation. No complication was recorded after surgery. CONCLUSION: Fluoro-navigation-assisted operation for the pelvic and acetabular fracture makes the surgery more precise, safer, and time-saving with less X-ray exposure.

Medial double-plating for fracture dislocations involving the proximal tibia.

Fracture dislocations of the knee involving the proximal tibia are difficult to treat because of the operative approach that maybe required and the instability of the construct. This paper evaluates the use of a two-incision approach with a medial double-plating technique. The clinical results of a case series of 42 patients collected prospectively are presented. At final follow-up 37 out of 42 (88%) had satisfactory reduction of the articular surface and 41 (98%) had satisfactory alignment. At one year postoperation there was no loss in reduction or alignment. The mean HSS score was 90.9 (s.d. 3.35, range 83 to 97). There were no superficial or deep infections, however four cases (10%) had a sanguinous effusion for more than one week postoperatively. It was concluded that the medial double-plating operation is an effective way of managing fracture dislocations involving the proximal tibia.