Objectives: A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C3D), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction.Methods: Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique.Results: CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions.Conclusion: This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C3D in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.
To determine the effectiveness of closed, intramedullary exchange nailing with reamed insertion for the treatment of femoral shaft nonunions previously treated with an intramedullary nail.Retrospective cohort study.Academic level I trauma center.Forty-two patients whose femoral shaft fracture was initially managed with an intramedullary nail, were subsequently treated by closed, intramedullary exchange nailing with reamed insertion for their femoral nonunion in our center. Seven patients had an infected nonunion as proved by intraoperative cultures.Closed, intramedullary exchange nailing with reamed insertion of a larger diameter nail.Radiographic and clinical evidence of fracture healing.Thirty-six patients (86%) had their fracture heal without further intervention. The average time to achieve union was 4 months after surgery. Of the 6 cases of exchange nailing failure, 3 were aseptic and 3 were septic. All these 6 patients healed after additional procedures. Lack of immediate weight bearing, open fractures, atrophic/oligotrophic nonunions, and infection were associated with treatment failure. A second nail larger by 2 mm or more than the original nail was associated with a higher success rate.Closed, intramedullary exchange nailing with reamed insertion for femoral shaft nonunions previously treated with intramedullary nails has proved to be a successful sole procedure in most cases. A nail at least 2 mm larger in diameter than the first nail should be used if possible. Risk factors of treatment failure should alert the surgeon to consider an alternative treatment to closed exchange nailing.
Background : Reverse oblique fractures (AO/OTA 31-A3) account for 5–23% of all intertrochanteric fractures and are challenging to manage. The Gamma 3-Proximal Femoral Nail (GPFN) and the Trochanteric Fixation Nail Advanced (TFNA) are two common cephalomedullary systems used to treat this fracture. No study has reported on outcomes with the TFN-A for reverse oblique fractures. This study aimed to compare outcomes and complication rates in patients with reverse oblique fractures, treated with either TFNA or GPFN. Patients and methods : A total of 203 patients with reverse oblique fractures (137 in the GPFN group and 66 in the TFNA group), were treated in our institution between June 2010 and May 2019. Data was collected on postoperative radiological variables including screw or blade location, and tip-apex distance (TAD). Data were also collected for non-orthopaedic complication rates and orthopaedic complications. A sub-group analysis was additionally performed for different nail lengths. Results : We found no significant difference in the overall rate of complications and revisions between the two groups. Patients treated with the 235 mm TFN-A nail sustained lower rates of cutout, compared to 180 mm GPFN (GPFN: 6% TFN-A: 0%, p = 0.043). The frequency of revision surgeries and malunions/non-unions did not differ significantly between the two groups and additionally showed no difference in the subgroup analysis. Conclusion : The 235 mm TFN-A was associated with lower rates of cut-out compared to the short GPFN for reverse oblique intertrochanteric fractures. Future well-designed prospective studies are warranted to investigate the role of the TFN-A in improving outcomes for such fractures.
Computer Assisted Orthopaedic Surgery (CAOS) was introduced in the late 1990's and early 2000's. Since then its application in orthopaedic trauma has been utilized mainly as augmented fluoroscopy for intraoperative navigation. From 2010 our center implemented an advanced system allowing further expansion of this technology.The aim of this study was to describe the experience with an advanced fluoroscopic based CAOS system in our center.The BrainLabTM Trauma 3.0 utilizes a handheld fluoroscope tracker, enables tracking of two anatomical objects and intraoperative planning. We implemented this system for the performance of 126 navigated procedures between the years 2011-2014. The procedures included 58 cases of navigated hip fracture pinning, 9 plate navigation for distal femoral fractures, 19 iliosacral screw insertions, 20 femoral fracture reductions, and 12 other procedures (acetabular screws, osteotomies etc).The mean age of patients was 52 years (range 16-82 years); 46 male and 80 female patients. The mean operating room time was 157 minutes (range 70 to 470 minutes). The average radiation required was 550 rad cm2 (~30 sec fluoroscopic time). Overall estimated additional OR time was estimated as 10-15 minutes for hip pinning, 15-20 minutes for pelvic iliosacral screws and 30-45 minutes of additional OR time for femur fracture reduction for length and rotation. In 5% of cases (6 patients), navigation was aborted due to technical reasons. No misplaced hardware due to the use of navigation was documented.CAOS is a powerful tool in trauma surgery with 95% success rate, with a reasonable added burden time. Although 3D navigation may be more useful in the pelvis, even two-dimensional navigation increases precision and implant placement. Femoral fracture reduction for accurate length and rotation control is solely enabled by CAOS. In the future, more time efficient and user-friendly systems will enable widespread use of these technologies in orthopaedic trauma.
Acute hematogenous osteomyelitis (AHO) has been noted mainly in open fractures injuring soft tissue immunological defenses and in immuneincompetent patients. Osteomyelitis complicating closed fractures in immunocompetent adult patients is, therefore, a rare clinical entity with scarce literature.We report a case of primary Staphylococcus aureus bacterial infection of a closed, humeral shaft fracture occurring in a previously healthy 28-year-old male patient. The patient was involved in a motorcycle accident and was admitted to the surgical ward with a chest drain. While hospitalized, a peak of fever was noted, but no source was found. Diagnosis of the closed fracture infection was noted on primary open reduction and internal fixation (ORIF), and although the patient was treated with antibiotics, local osteomyelitis developed. Treatment including serial debridements utilizing gentamycin beads and an additional ORIF procedure until the full union was achieved. The patient regained full, painless, motion of the arm and shoulder.Although AHO complicating a closed fracture in immunocompetent adults is very rare, it should not be overlooked, and special attention should be sought in such cases. Meticulous debridement and rigid fixation are utmost for the eradication of infection and fracture union. Patients presenting with such infections should, therefore, be followed closely and treated promptly.
Background: The recent development of three-dimensional (3D) technologies introduces a novel set of opportunities to the medical field in general, and specifically to surgery. The preoperative phase has proven to be a critical factor in surgical success. Utilization of 3D technologies has the potential to improve preoperative planning and overall surgical outcomes. In this narrative review article, the authors describe existing clinical data pertaining to the current use of 3D printing, virtual reality, and augmented reality in the preoperative phase of bone surgery. Methods: The methodology included keyword-based literature search in PubMed and Google Scholar for original articles published between 2014 and 2022. After excluding studies performed in nonbone surgery disciplines, data from 61 studies of five different surgical disciplines were processed to be included in this narrative review. Results: Among the mentioned technologies, 3D printing is currently the most advanced in terms of clinical use, predominantly creating anatomical models and patient-specific instruments that provide high-quality operative preparation. Virtual reality allows to set a surgical plan and to further simulate the procedure via a 2D screen or head mounted display. Augmented reality is found to be useful for surgical simulation upon 3D printed anatomical models or virtual phantoms. Conclusions: Overall, 3D technologies are gradually becoming an integral part of a surgeon’s preoperative toolbox, allowing for increased surgical accuracy and reduction of operation time, mainly in complex and unique surgical cases. This may eventually lead to improved surgical outcomes, thereby optimizing the personalized surgical approach.
