Navigated pedicle screw insertion with the Surgivisio system: Malposition rate and risk factors - about 648 screws.

PURPOSE: Pedicle screw malposition rates vary greatly in scientific literature depending on the chosen criteria. Different techniques have been developed to lower the risk of screw malposition. Our primary objective is to evaluate the malposition rate associated with the use of the Surgivisio navigation system and to identify risk factors for screw malposition. The secondary objectives are to assess operating time and radiation data. MATERIALS AND METHODS: We performed a monocentric retrospective consecutive case series. All patients operated for pedicle screw implantation using the Surgivisio system between September 2017 and June 2020 were included. Screw positioning was evaluated on postoperative CT scans using Heary and Gertzbein classifications. Thirteen potential risk factors for screw malposition were hypothesized and tested with a univariate and multivariate analysis. RESULTS: Six hundred and forty-eight screws could be evaluated in 97 patients. Our study reported a 92.4% satisfactory screw implantation rate with a mean operative time per screw of 14.5±6.7minutes and a patient effective dose of 0.47±0.31 mSv per screw. One screw was neurotoxic and required an early revision (0.15%). Three risk factors for screw malposition have been identified in a multivariate analysis: female gender (OR=2.13 [1.11; 4], p=0.0219), an implantation level above D10 (OR=2.17 [1.13; 4.16], p=0.0197), and an "open" surgery (as opposed to percutaneous) (OR=3.47 [1.83; 6.56], p=0.0002). CONCLUSION: Pedicle screw malposition rate and operative time with the Surgivisio navigation system are comparable with those reported in scientific literature. We theorized that intraoperative patient reference displacement could be a major cause of navigation failure. LEVEL OF EVIDENCE: IV.

Fragility fractures of the pelvis: First 48 cases of surgical treatment at a level 1 trauma center in France.

INTRODUCTION: Longer life expectancy is accompanied by a higher incidence of fragility fractures of the pelvis (FFP), which has repercussions on mortality and nursing home admissions. Given the paucity of data at French healthcare facilities, we carried out a retrospective study to (1) evaluate how surgical treatment of FFP with posterior displacement (type III and IV according to Rommens and Hofmann) affects a patient's pain, functional status and ability to stay at home and (2) evaluate the postoperative complications and mortality rate. HYPOTHESIS: Surgery for posteriorly displaced FFP will relieve pain and preserve the patient's independence. METHODS: All the patients over 65 years of age who were operated on for a posterior FFP between January 2015 and August 2020 were included in this prospective, single-center study. The demographics, fracture type, details of the surgical treatment, complications and mortality were analyzed. Pain (visual analog scale, VAS), functional status (Activity of Daily Living [ADL] and Instrumental Activity of Daily Living [IADL]), mobility (Parker score) and rates of nursing home admissions were compared before the fracture, after surgery and at a mean follow-up of 28 months (minimum follow-up of 1 year). RESULTS: Forty-eight patients with a mean age of 75 years were included. Twenty-four of these patients (50%) had at least two comorbidities. The FFPs were either type IV (31/48; 65%) or type III (17/48; 35%). The mean VAS for pain was significantly lower on the first day postoperative (3.5 versus 4.8; p=0.02). This significant reduction continued upon discharge from the hospital (1.95; p=0.003) and persisted at the mean follow-up of 28 months (2.2; p=0.64). The complication rate was 15% (7/48) and the mortality rate at the final review was 15% (7/48). Among the surviving patients, 81% (29/36) returned to living at home. The ADL (5.1 versus 5.8; p=0.09), IADL (5.9 versus 6.9; p=0.15) and Parker score (6.8 versus 8.2; p=0.08) at the final review were not significantly different from the values before the fracture. CONCLUSION: This is the first French study of patients operated on for an FPP. Fixation of posteriorly displaced fractures allows surviving patients to retain their mobility. Pain relief is achieved quickly and maintained during the follow-up period. Thus, our initial hypothesis is affirmed. The complication rate is not insignificant; given the complexity of this surgery, percutaneous treatment is preferable. LEVEL OF EVIDENCE: IV; retrospective study.

Navigated Cementoplasty With O-Arm and Surgivisio: An Ambispective Comparison With Radiation Exposure.

BACKGROUND: Vertebral compression fractures (VCF) are usually treated by cementoplasty. Computerized navigation allows more accurate surgery without additional imaging acquisition for guidance and related radiation exposure. New technologies trend to optimize the irradiation for patients and surgeons. The objective was to investigate the radiological results and radiation exposure of O-arm navigation compared with the all-in-one 2-dimensional/3-dimensional (2D/3D) Surgivisio device in navigated cementoplasty procedures. METHODS: Patients in the O-arm group comprised an O-arm prospective cohort as well as previous patients. Operations for VCF by navigated cementoplasty took place over 18 months. Patients in the Surgivisio group were the first patients operated on using Surgivisio and were prospectively recruited. Demographic, operative, and irradiation data were collected, as well as the image quality subjectively evaluated by the surgeon. The vertebal filling was evaluated using the Garnier classification and quoted as satisfactory, acceptable, or poor. The effective dose in millisievert (mSv) was calculated for radiation exposure estimation, and the absolute risk of cancer (AR) in percent equivalent to a whole-body irradiation was also calculated. RESULTS: A total of 123 patients were included: 62 in the O-arm group and 61 in the Surgivisio group. A total of 166 vertebrae were analyzed. Compared with the Surgivisio group, the effective dose was significantly higher in the O-arm group, with a mean of 11.47 vs 1.14 mSv, respectively (P < 0.001). The 2D part of the effective dose received by the surgeon was significantly higher in the O-arm group, with an average of 2.25 vs 0.47 mSv, respectively (P < 0.001). Overall AR followed the same trend, with a mean of 4.9 × 10-4% in the O-arm group and 5.7 × 10-5% in the Surgivisio group (P < 0.001). Operative time was significantly higher in the O-arm group (34.52 vs 30.12 minutes respectively, P = 0.03). Image quality was similarly sufficient in 3D, but in 2D, image quality was significantly better in the O-arm group (P = 0.01). Vertebral filling was significantly better in the O-arm group, with 100% of results reported as satisfactory and acceptable versus 85% in the Surgivisio group (P < 0.001). CONCLUSIONS: The O-arm delivered a 10-times higher effective dose during navigated cementoplasty in comparison with the Surgivisio device. The O-arm also had a longer operative time, but it had better image quality and radiological results.

Clinical and radiological outcomes of antegrade posterior column screw fixation of the acetabulum.

INTRODUCTION: Antegrade posterior column screw fixation (APCS) provides stable fixation while reducing the complications related to dual acetabular approaches. The objective of this study was to present the radiological and clinical outcomes of fixation of the posterior column of the acetabulum through a single anterior approach. HYPOTHESIS: APCS will produce better clinical and radiological outcomes relative to not placing any screws in the posterior column. PATIENTS AND METHODS: This was a retrospective single-center study of 69 patients operated through a single anterior approach for a both-column fracture of the acetabulum between 2014 and 2018. Patients were divided into two groups (APCS+, n=24 and APCS-, n=45) depending on whether the posterior column was fixed with an antegrade lag screw or not. The radiological outcomes were defined by the quality of the reduction according to Matta. The clinical outcomes were evaluated using the Harris Hip score and Merle Postel D'Aubigné (MDP) score at the final assessment. A sequential hierarchical analysis was done with a Chi2 test for the radiological criterion and Student's t test for the clinical outcomes. RESULTS: In the APCS+ group, the reduction was anatomical in 71% (17/24) of patients, imperfect in 12% (3/24) and poor in 17% (4/24). In the APCS- group, the reduction was anatomical in 33% (15/45) of patients, imperfect in 31% (14/45) and poor in 35% (16/45). This difference between groups was statistically significant (p=.012). The differences between groups in the Harris (p=.201) and MDP (p>.05) scores were not significant. Mean irradiation in the APCS+ group was significantly higher (114.8 cGy.cm-2) relative to the APCS- group (39.8 cGy.cm-2) (p<.001). None of the patients in the APCS+ group underwent a subsequent total hip arthroplasty, while 8 patients from the APCS- group did (p=.031). The differences in the postoperative complications were not statistically significant. DISCUSSION: APCS yields satisfactory radiological and clinical outcomes without increasing the complication rate; this must be balanced out against the additional irradiation. LEVEL OF EVIDENCE: III.

Screw misplacement in percutaneous posterior pelvic iliosacral screwing with and without navigation: A prospective clinical study of 174 screws in 127 patients.

BACKGROUND: Recent studies of iliosacral screw fixation performed using intraoperative navigation systems have shown promising results. The Surgivisio Platform is a new-generation three-dimensional intraoperative navigation tool that has been used at our institution for 2years. The aim of this prospective study was to assess the contribution of navigation in terms of iliosacral screw positioning accuracy and of radiation exposure, by comparing outcomes with vs. without navigation. HYPOTHESIS: Navigation allows more accurate percutaneous iliosacral screw positioning regardless of the type of screw fixation (with sacral dysmorphism and/or cemented screw fixation and/or multiple screw fixation). MATERIALS AND METHODS: Between January 2018 and December 2019, consecutive patients who underwent percutaneous iliosacral screw fixation of pelvic ring fractures without vertical instability were included in this single-centre prospective study. Screw position accuracy was evaluated by postoperative high-resolution computed tomography (HRCT). Operative time, radiation dose, and complications were recorded. RESULTS: We included 127 patients with 174 iliosacral screws, of which 129 were positioned under fluoroscopic guidance and 45 using navigation. According to the modified Gras classification, 7% (12/174) of the screws were incorrectly positioned and 2% (4/174) required repositioning. The frequency of screw malposition was not significantly different between the fluoroscopy and navigation groups (8.5%, 11/129 vs. 2.2%, 1/45, respectively; p=0.19). However, screw position in dysmorphic sacra was significantly better with navigation (p=0.04), whereas no significant difference in final screw position was found for cemented or multiple screw implantations. In the navigation group, the operative time was significantly longer (28.2min vs. 21.6min, p=0.003), and the mean dose-area product significantly greater (6.6Gy·cm2 vs. 4.9Gy·cm2, p=0.02). The complication rates were not different between the two groups. CONCLUSION: In patients who have pelvic ring fractures without vertical instability, navigation of percutaneous iliosacral screw placement using the Surgivisio Platform improves screw positioning in dysmorphic sacra, at the cost of a longer operative time and greater radiation exposure of the patient. LEVEL OF EVIDENCE: II, prospective study.

Complications and outcomes in 69 consecutive patients with floating hip.

BACKGROUND: Floating hip is a rare and potentially serious injury. The objective of this study was to evaluate our management strategy for patients with floating hip. HYPOTHESIS: A standardized strategy with specialised multidisciplinary management is associated with a low mortality rate. METHODS: Consecutive patients who had surgery to treat floating hip between January 2010 and December 2019 were included in this single-centre retrospective study. Epidemiological, clinical, and radiological data were collected and analysed. Patients were managed according to a standardised strategy adapted to the haemodynamic status and type of floating hip (type A, femoral and pelvic ring fractures; type B, femoral and acetabular fractures; and type C, femoral, acetabular, and pelvic ring fractures). The clinical outcome at last follow-up was determined by a telephone interview, based on the Majeed and Oxford scores, sports resumption, and work resumption. To assess the radiological outcomes, we applied Matta's criteria for the acetabulum and Tornetta's criteria for the pelvic ring. RESULTS: We included 69 patients with a mean age of 38.5 years. Among them, 39 (57%) had haemodynamic instability requiring embolisation (n=15, 22%) or multiple blood transfusions (n=24, 35%). Type A injuries predominated (n=57, 83%). The need for multiple blood transfusions was significantly associated with type C floating hip, underlining the risk of heavy bleeding with this injury. Two (3%) patients died. When management was complete, the reduction was anatomical or satisfactory for 76% (13/17) of the acetabula according to Matta's criteria (maximum residual displacement <3mm) and for 85% (56/66) of the pelvic rings according to Tornetta's criteria (maximum residual displacement <10mm). One or more complications occurred in 45 (65%) patients. After a mean follow-up of 5 years, the mean Oxford Hip Score in patients with acetabular fractures was 35.5 and the mean Majeed score in patients with pelvic ring fractures was 71.5. Only 30% of patients were able to resume physical activities at the former level and to return to their former professional activities. CONCLUSION: Type C floating hip, which combines fractures of the pelvic ring and acetabulum, carries a high risk of bleeding. Special attention should be directed to the reduction of pelvic ring fractures, to avoid malunion. Acetabular fractures that are complex in the Letournel classification carry a risk of imperfect reduction. The results of this study confirm the severity of these rare injuries and the need for specialised multidisciplinary management according to a standardised strategy that is appropriate for the haemodynamic status and type of floating hip (A, B, or C). LEVEL OF EVIDENCE: IV; retrospective study.

Does intraoperative 3D navigation improve SpineJack vertebral augmentation in thoracic and lumbar compression fracture?

INTRODUCTION: The aim of this retrospective study was to evaluate the effect of navigation on the positioning of the SpineJack implant in the treatment of thoracic and lumbar compression fractures. METHODS: Between January 2018 and December 2019, all patients operated on for thoracic or lumbar fracture using the SpineJack device in stand-alone were included in this single-center study. The positioning of the SpineJack implant was analyzed on axial CT views by measuring the angle between the axis of the pedicle and the axis of the final implant. The relationships between implant positioning and the use of navigation or fluoroscopy, pedicle dimensions and levels of injury were analyzed. Surgical time, radiation exposure, radiological findings and complications were assessed. RESULTS: One hundred patients were included, for 103 fractured vertebrae and a total of 205 implants, 148 placed under standard fluoroscopy and 57 with the Surgivisio navigation system. For pedicle diameters≥5mm (165 implants), the positioning of the implant relative to the axis of the pedicle was significantly better in the navigation group: 2°±1.4° (range, 0-7°) in the fluoroscopy group versus 1.2°±1.1° (range, 0-5°) in the navigation group (p=0.04). There were no significant differences in reduction of vertebral kyphosis angle or mean operating time. Dose area product (DAP) was significantly higher with navigation: 4.43Gy.cm2 versus 0.47Gy.cm2 (p<0.001) and dose to the surgeon significantly lower: 0.5 versus 1.6µSv (p<0.001). No difference was found regarding complications. Subgroup analysis showed significantly greater operative time and patient irradiation in the fluoroscopy group when pedicle diameter was less than 5mm. CONCLUSION: This study demonstrates the interest of navigation for positioning the SpineJack implant with respect to the pedicle axis in vertebrae with pedicle diameter≥5mm. This study also confirmed the reliability of navigation and lower radiation dose to the surgeon, regardless of the fracture level. Navigation reduced operating time and patient irradiation for vertebrae with pedicle diameter<5mm. LEVEL OF EVIDENCE: IV; retrospective study.

EOS stereographic assessment of femoral shaft malunion after intramedullary nailing. A prospective series of 48 patients at 9 months' follow-up.

INTRODUCTION: The aim of the present study was to assess femoral shaft malunion following anterograde intramedullary nailing, using low-dose EOS stereoradiography. The study hypothesis was that our surgical technique is associated with radiological rotation disorder rates equivalent to those reported in the literature. METHODS: All patients with unilateral femoral shaft fracture treated by anterograde nailing between January 2014 and December 2016 and followed up in our structure were included in a single-center prospective study. The main endpoint was≥15° transverse malrotation compared to the contralateral side as measured on EOS stereoradiography. Correlations between malrotation and Harris Hip and SF12 functional scores were assessed, as were risk factors for onset of shaft malunion in rotation. Forty-eight patients with a mean age of 31.4 years were analyzed at a mean 9.3 months' follow-up. RESULTS: Stereoradiographic malrotation was found in 29.2% of patients. Mean anteversion was 18.5±13.8°. In 2.1% of patients, symptomatic rotation disorder required revision surgery. No correlations emerged between transverse malrotation and functional scores (p>0.05). Risk factors for malrotation comprised multi-site fracture (p=0.04), surgeon's inexperience (p=0.04), and open reduction (p=0.01). CONCLUSION: The present radiologic malrotation rate was comparable to those reported in the literature, using the EOS stereoradiographic system, which provides precise assessment of rotation disorder following closed nailing of femoral shaft fracture. LEVEL OF EVIDENCE: III; prospective study without control group.

3D-imaging in percutaneous spine surgery using the Surgivisio system.

The Surgivisio system is a new generation of intraoperative 3D imaging, used in our institution for pedicle insertion in minimally invasive spine surgery since January 2018. The purpose of this technical note is to describe the Surgivisio system, its advantages and its limitations, in percutaneous spinal surgery. Results of the first year of use were analyzed, in a series of 29 patients, to evaluate accuracy of pedicle screw insertion, operative time and radiation exposure. On the Heary and Gertzbein classifications, 95.5% of pedicle screw placements (107/112) were rated as acceptable. Mean operative time was 29.3min per vertebra; mean radiation exposure per vertebra was 0.61 mSv. The Surgivisio system is an effective navigation tool for pedicle screw insertion in minimally invasive spinal surgery, with acceptable radiation exposure and operative time for each navigated vertebra. LEVEL OF EVIDENCE: II, prospective cohort study.

Tuberosity healing in reverse shoulder arthroplasty in traumatology: Use of an offset modular system with bone graft.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) has become a common treatment in displaced proximal humeral fracture (PHF) in elderly patients due to inconstant results with osteosynthesis or hemiarthroplasty. RSA allows a good anterior elevation but rotational results are more random and depend on tuberosity healing. HYPOTHESIS: Use of an offset modular system (OMS) on the prothesis improve tuberosity healing and functional results. MATERIAL AND METHODS: This retrospective cohort analysed radiological and clinical outcomes at least one year after the use of RSA Humelock II Reversed (Fx Solutions) after a displaced PHF Neer 3 or 4 in patients over 70 years. The first criterion was tuberosity healing with or without the use of the OMS device on radiographs. The second criterion was a clinical analysis of active range of motion (ROM), anterior elevation (AAE), external and internal rotations (ER, IR), Constant, DASH, SSV, VAS scores according to tuberosity healing. We also analysed radiological and clinical complications. RESULTS: We analysed from November 2013 to May 2018 thirty-four RSA. Mean age was 78±5,7 years, mean follow up was 18±7,2 months and the mean tuberosity healing rate was 79%. Mean ROM were: 117±24 (AAE), 18̊±18 (ER) and L2 (IR). On the first analysis, healing tuberosity with cage was present on 24 (92%) patients versus 3 (37,5%) without (p<0,005). The second analysis showed a non-significant improvement on ER, IR, Constant, DASH and SSV. Complications found were three removal of prothesis after infection, one axillary nerve lesion, one ulnar paraesthesia and one humeral loosening. CONCLUSION: The use of the OMS cage allows a better consolidation of tuberosities in a significant way but no significant clinical effects was highlighted due to a small patient number in the study. LEVEL OF EVIDENCE: level III, retrospective cohort.

Early versus delayed corpectomy in thoracic and lumbar spine trauma. A long-term clinical and radiological retrospective study.

AND BACKGROUND DATA: Many authors have demonstrated the necessity of reconstruction of the anterior column in spinal trauma with vertebral body collapse or nonunion. There is no publication comparing the result depending on the time between trauma and anterior reconstruction of the vertebral body. OBJECTIVE: To compare long-term clinical and radiological results between early and late anterior vertebral body reconstruction with expandable cages in patients with thoracic and lumbar spine trauma. HYPOTHESIS: An early anterior reconstruction of thoracolumbar fractures provides better clinical and radiological outcomes than a delayed one. MATERIALS AND METHODS: A retrospective clinical study was carried out with 44 consecutive patients with injuries of the thoracic and lumbar spine treated operatively with combined posterior stabilization and anterior reconstruction with an expandable implant for vertebral body replacement. All patients were evaluated with EOS full-spine radiograph and CT-scan. The mean follow-up was 5.1 years. Clinical result was evaluated with ODI, SF12, VAS back pain, return to work and sport. Radiological result was evaluated with regional kyphosis angle (RKA) evolution, fusion rate and sagittal alignment. In Group A, twenty-nine patients underwent an early anterior reconstruction within 3 weeks after trauma. The indication of vertebral body reconstruction was placed after post-operative CT-scan for a Mc Cormack score≥7. In Group B, fifteen patients underwent a late anterior reconstruction after diagnosis of nonunion by the combination of pain and CT-scan after 1 year. RESULTS: Clinical scores and scales were significantly better for patients operated early in Group A. Return to work and activities were significantly more important in Group A too. The mean RKA correction with posterior reduction was 9.3°. The secondary anterior approach permit to reduce 2.9° more. At last follow-up, the loss of reduction was 4.3°. There was no significant difference between groups for those results. No difference in fusion rate was observed between groups. There was no significant difference between groups in the sagittal alignment excepted for SVA that was higher for Group B while remaining under a normal value of 50mm. CONCLUSION: Early anterior vertebral body reconstruction for fractures gives better clinical results than delayed reconstruction for patients with diagnosis of nonunion in patients with thoracic and lumbar spine trauma. Moreover, the shorter the time from trauma to operation, the better the sagittal reduction of kyphosis. The use of expandable titanium cage is a good way to perform and maintain this reduction. LEVEL OF EVIDENCE: IV, retrospective study.

Operative versus non-operative treatment of displaced acetabular fractures in elderly patients.

BACKGROUND: Acetabular fracture treatments in elderly patients are not well codified. PURPOSE: The aim of the study was to determine if, for active elderly patients, the clinical results after surgical treatment of displaced acetabular fractures are better than for non-operative treatment. METHODS: All active patients over 60 years with a Parker score higher than 6, managed for displaced acetabular fracture between 2005 and 2014, were included in this single-center retrospective study. Clinical outcomes were compared according to the therapeutic option (operative or non-operative) and the fracture pattern (anterior fracture that requires open reduction and internal fixation or posterior fracture that requires total hip arthroplasty). RESULTS: Among the 82 patients with Parker score higher than 6, 44 were treated non-operatively and 38 were operated. Forty-seven had anterior fracture (AF) and 35 had posterior fracture (PF). In the AF group, the autonomy scores were better for operative than non-operative patients (p < 0.05) with a PARKER score 7.8 (7-8) versus 5.4 (1-9); ADL score 5.7 (4-6) versus 4.4 (1-6) and IADL score 7.6 (6-8) versus 4.2 (0-8). In the PF group, the autonomy scores were better for operative than non-operative patients (p < 0.05) with a PARKER score 7.3 (4-9) versus 5.6 (2-9), ADL score 5.3 (2-6) versus 4.4 (1-6) and IADL score 5.6 (2-8) versus 4.1 (1-7). Regarding clinical outcomes, the HARRIS and PMA scores were better for operative patients (p < 0.05). CONCLUSION: Surgical treatment in elderly patients with displaced acetabular fractures is associated with better clinical outcomes than non-operative treatment when the autonomy level is comparable.

Posterior transiliac plating in vertically unstable sacral fracture.

The aim of the present technical note is to describe the posterior transiliac plating method. Acute-phase clinical and radiological results in a continuous series of 10 vertically unstable fractures are presented. Reduction was good or excellent in 70% of cases, and clinical results were good or excellent in 80% on Hannover and Majeed scores, with mean Majeed score of 71.8±17. Complications comprised 3 cases of early postoperative sepsis requiring surgical lavage, and 4 cases of hardware removal due to discomfort. At last follow-up, consolidation was systematic. Reduction was more difficult with longer time to surgery and greater initial displacement. Posterior transiliac plating provided immediately effective fixation in vertically unstable pelvic fracture.

Role of 3D intraoperative imaging in orthopedic and trauma surgery.

Intraoperative three-dimensional (3D) imaging is now feasible because of recent technological advances such as 3D cone-beam CT (CBCT) and flat-panel X-ray detectors (FPDs). These technologies reduce the radiation dose to the patient and surgical team. The aim of this study is to review the advantages of 3D intraoperative imaging in orthopedic and trauma surgery by answering the following 5 questions: What are its technical principles? CBCT with a FPD produces non-distorted digital images and frees up the surgical field. The high quality of these 3D intraoperative images allows them to be integrated into surgical navigation systems. Human-robot comanipulation will likely follow soon after. Conventional multislice CT technology has also improved to the point where it can be used in the operating room. What can we expect from 3D intraoperative imaging and which applications have been validated clinically? We reviewed the literature on this topic for the past 10 years. The expected benefits were determined during the implantation of pedicular screws: more accurate implantation, fewer surgical revisions and time savings. There are few studies in trauma or arthroplasty cases, as robotic comanipulation is a more recent development. What is the tolerance for irradiation to the patient and surgical team? The health drawbacks are the harmful radiation-induced effects. The deterministic effects that we will develop are correlated to the absorbed dose in Gray units (Gy). The stochastic and carcinogenic effects are related to the effective dose in milliSievert (mSv) of linear evolution without threshold. The International Commission on Radiological Protection (ICRP) states that irradiation for medical purposes with risk of detriment is acceptable if it is justified by an optimization attempt. The radioprotection limits must be known but do not constitute opposable restrictions. The superiority of intraoperative 3D imaging over fluoroscopy has been demonstrated for spine surgery and sacroiliac screw fixation. How does the environment need to be adapted? The volume, access, wall protection and floor strength of the operating room must take into account the features of each machine. The instrumentation implants and need for specialized staff result in additional costs. Not every system can track movements during the CBCT acquisition thus transient suspension of assisted ventilation may be required. Is it financially viable? This needs to be calculated based on the expected clinical benefits, which mainly correspond to the elimination of expenses tied to surgical revisions. Our society's search for safety has driven the investments in this technology. LEVEL OF EVIDENCE: V, Expert opinion.

Clinical and radiological outcomes in thoracolumbar fractures using the SpineJack device. A prospective study of seventy-four patients with a two point three year mean of follow-up.

PURPOSE: The aim of this study was to assess clinical and radiological results of SpineJack on the treatment of vertebral body fractures in a continuous prospective series of patients. MATERIAL AND METHODS: Between May 2012 and April 2015, all patients operated using the SpineJack device were prospectively included in this monocentric study. Demographic data, clinical, and radiological results were recorded. Complications and surgical managements were recorded. RESULTS: At a mean follow-up of 2.3 years, 74 patients with 77 fractured vertebrae were included. The stand-alone SpineJack group comprised 60 patients with 63 fractured vertebrae (group 1) and the group with additional posterior fixation 14 patients with 14 fractured vertebrae (group 2). The average initial vertebral wedge angle was 13.3 ± 6.1 degrees for group 1 and 15.3 ± 5.7 degrees for group 2 (p = 0.25). Post-operative values were 6.5 ± 4.6 degrees for group 1 and 5.1 ± 3.9 degrees for group 2 (p = 0.31). The differences within the same group were highly significant (p < 0.0005). The loss of reduction at last follow-up was 0.8 ± 1.6 degrees in group 1 and 0.6 ± 2.0 degrees in group 2 (p = 0.77). Subjective results were considered as very good or good for 57 patients (95%) in group 1 and for 11 patients (79%) in group 2, p = 0.07. CONCLUSION: The SpineJack seems to be a promising tool in the treatment of traumatic vertebral fractures with a correction in the sagittal plane comparable with what can be found in the literature.

Effectiveness of closed reduction and percutaneous fixation of isolated sacral fractures. Functional outcomes and sagittal alignment after 3.6 years in 20 patients.

BACKGROUND: Displaced U- or H-shaped sacral fractures (Roy-Camille Grade II or III) are treated at our institution by early transcondylar traction and manual countertraction, hyperlordosis induced by a pad positioned under the lumbo-sacral junction, and percutaneous ilio-sacral screw fixation. The objective of this study was to evaluate the outcome of this technique used in a level 1 trauma centre. Hypothesis Our early reduction technique provides anatomical reduction of U- or H-shaped sacral fractures by correcting the sagittal malalignment due to the intra-sacral kyphosis, thereby obviating the need for decompression laminectomy and improving neurological outcomes. MATERIAL AND METHODS: We retrospectively evaluated 20 patients treated for U- or H-shaped sacral fractures using our original reduction technique followed by percutaneous fixation only. Mean follow-up was 42.4 months. Mean displacement of the S1 posterior wall was measured on computed tomography scans obtained before and after surgery. Pelvic incidence (PI) and measured lumbar lordosis (LLm) were evaluated on standard radiographs before surgery and on stereoradiographs after surgery. Expected lumbar lordosis (LLe) was computed as LLe=PI+9°. A 25% or greater difference between LLe and LLm defined lumbo-pelvic mismatch. At last follow-up, functional outcomes were assessed based on the Majeed score and the Iowa Pelvic Score (IPS), and a neurological examination was performed. RESULTS: Mean S1 posterior wall displacement in the sagittal and axial planes was 64% and 64.8%, respectively, before surgery versus 5.6% and 15.2%, respectively, after surgery. At last follow-up, LLm was 63.5° and the LLe-LLm difference was 11.2%; only 3 (15%) patients had lumbo-pelvic mismatch at last follow-up. The mean Majeed score and IPS values were 86.6 and 79, respectively, and lumbo-pelvic mismatch correlated significantly with a worse functional outcome defined as a Majeed score below 75 (p=0.0087). At last follow-up, the neurological dysfunctions were improved in 90% of patients, and 70% of patients had achieved a full neurological recovery. DISCUSSION/CONCLUSION: Given these encouraging findings, we advocate early reduction and percutaneous fixation of U- or H-shaped sacral fractures. Although technically demanding, this method restores the normal pelvic parameters and improves neurological function. LEVEL OF EVIDENCE: IV, retrospective observational study.

Outcomes of acetabular fractures in the elderly: a five year retrospective study of twenty seven patients with primary total hip replacement.

PURPOSES: Open reduction and internal fixation (ORIF) in osteoporotic acetabular fractures is quite difficult with high risk of implant failure. Total hip arthroplasty (THA) may be an effective option for treating acetabular fractures in appropriately selected patients, with immediate full weightbearing. The aim of the study was to evaluate the functional outcomes of primary THA for acetabular fractures in elderly patients. METHODS: Between 2010 and 2015, 27 elderly patients operated for acetabular fractures by primary THA were included. The surgical technique associated plate stabilization of both acetabular columns with THA using an acetabular reinforcement cross-plate. Mean age was 68.5 years (57-84) and mean ASA was 2 (1-3). The mean follow-up was four years. RESULTS: The mean Harris score was 70.4 ± 23 (24-90), and the mean Postel-Merle Aubigné (PMA) score was 14.3 ± 4 (7-18). For 17 patients with rank of pre-operative Devane 4, the post-operative rank was unchanged (p < 0.05). Twenty patients (74%) were satisfied by the surgical treatment. Twenty post-operative complications (74%) were found. Two patients died during follow-up (7%). CONCLUSIONS: Primary THA for acetabular fracture in the elderly population might be a good therapeutic option that allows return to the previous daily life activity. Three patients (11%) became bedridden, and four patient's skiers (15%) returned to skiing. However, this surgery is difficult and selection of elderly patients, i.e., with acetabular fractures who are expected to get a poor result with ORIF, i.e., fracture patterns with posterior wall lesion and marginal impaction, for primary THA in an experienced centre provides satisfactory clinical results.

Total Talar Prosthesis Replacement after Talar Extrusion.

Dislocation of the talus is a serious and extremely rare injury, with 86 cases reported in the published data in 20 years. The reference standard for case management involves replacement of the dislocated talus to restore the height and function of the tibiotalar joint. The risk of avascular necrosis remains very high, and the standard treatment in such cases is tibiotalar arthrodesis. We report the case of total dislocation of the talus, which was treated with the insertion of a custom total talar prosthesis affixed directly to the tibial cartilage at 6 months after injury. At the 2-year follow-up point, the preliminary results were rather encouraging, with well-functioning activity and an improved American Orthopaedic Foot and Ankle Society foot function scale score increasing from 11 to 77 of 100 and a Short-Form 36-item Health Survey score increasing from 17 to 82. Much longer follow-up periods are necessary to evaluate longer term trends.

Part 2: outcome of acetabular fractures and associated prognostic factors-a ten-year retrospective study of one hundred and fifty six operated cases with open reduction and internal fixation.

QUESTIONS/PURPOSES: The aim of this study was to identify prognostic factors associated with a poor quality of reduction and their relationships. METHODS: Data from medical charts for all patients admitted with acetabular fractures operated by open reduction and internal fixation (ORIF) from 2005 to 2014 were extracted. A total of 156 patients with a mean age of 40.3 years were included. All patients were reviewed at six months of follow-up. The prognostic factors analyzed were clinical and radiological factors. A new radiological parameter was also studied: the scanographic roof-arc angle. Specific statistical analysis was performed using a logistic regression model. RESULTS: Using a multivariate analysis logistic regression model: roof impaction (p = 0.001; OR = 6.59; CI 95% [2.01-20.97]), transverse + posterior wall (p = 0.03, OR = 2.52; CI 95% [1.46-13.65]) and surgeons in training (p = 0.02; OR = 1.24; CI 95% [1.07-3.32]) were three independent prognostic factors. Lower values of medial and posterior scanographic roof-arc angle were associated with unsatisfactory reduction. A significant association between unsatisfactory reduction and posterior roof arc angle < 61° was found. CONCLUSIONS: Three independent prognostic factors associated with a risk of unsatisfactory reduction in ORIF for acetabular fractures were identified: roof impaction, transverse + posterior wall fracture and surgeons in training. Scanographic roof-arc angle seems to be a new prognostic factor. Level of Evidence Level 4 retrospective study.