Early effectiveness of computer navigation system-assisted transiliac-transsacral screws placement for posterior pelvic ring injuries_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CAO Wenhao ^1,2 , ZHU Zhengguo ³ , QI Hongzhe ^1,4 , TANG Junjun ² , ZHANG Wei ⁵ , LI Jiaqi ^1,2 , LI Shuangcheng ^1,2 , WANG Zhonghe ² , LI Changda ² , ZHOU Feng ⁵ , LIU Haoyang ⁵ ,  CHEN Hua ^2,6 ,  TANG Peifu ^2,6

1. Chinese PLA General Hospital Medical School, Beijing, 100853, P. R. China;
2. Department of Orthopaedic Trauma, the Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, P. R. China;
3. Department of Orthopaedics, Aerospace Center Hospital, Beijing, 100049, P. R. China;
4. Chinese PLA Strategic Support Force Medical Center, Beijing, 100101, P. R. China;
5. AI Sports Engineering Lab, School of Sports Engineering, Beijing Sport University, Beijing, 100084, P. R. China;
6. National Clinical Research Center for Orthopaedics & Sports Rehabilitation in China, Beijing, 100048, P. R. China;

Corresponding author：

CHEN Hua, Email: chenhua0270@126.com; TANG Peifu, Email: pftang301@126.com

Keywords：

Pelvic fractures; fluoro-navigation; transiliac-transsacral screw; minimally invasive treatment

DOI：

10.7507/1002-1892.202306092

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Objective To investigate the early effectiveness of transiliac-transsacral screws internal fixation assisted by augmented reality navigation system HoloSight (hereinafter referred to as “computer navigation system”) in the treatment of posterior pelvic ring injuries. Methods A retrospective analysis was made in the 41 patients with posterior pelvic ring injuries who had been treated surgically with transiliac-transsacral screws between June 2022 and June 2023. The patients were divided into navigation group (18 cases, using computer navigation system to assist screw implantation) and freehand group (23 cases, using C-arm X-ray fluoroscopy to guide screw implantation) according to the different methods of transiliac-transsacral screws placement. There was no significant difference in gender, age, body mass index, causes of injuries, Tile classification of pelvic fracture, days from injury to operation, usage of unlocking closed reduction technique between the two groups (P>0.05). The time of screw implantation, the fluoroscopy times, the guide wire adjustment times of each screw, and the incidence of complications were recorded and compared between the two groups. The position of the transiliac-transsacral screw was scanned by CT within 2 days after operation, and the position of the screw was classified according to Gras standard. Results The operation was successfully completed in both groups. The time of screw implantation, the fluoroscopy times, and the guide wire adjustment times of each screw in the navigation group were significantly less than those in the freehand group (P<0.05). There were 2 cases of incision infection in the freehand group, and the incision healed by first intention after active dressing change; there was no screw-related complication in the navigation group during operation and early period after operation; the difference in incidence of complications between the two groups (8.7% vs. 0) was not significant (P=0.495). According to the Gras standard, the screw position of the navigation group was significantly better than that of the freehand group (P<0.05). Conclusion Compared with the traditional freehand method, the computer navigation system assisted transiliac-transsacral screws internal fixation in the treatment of posterior pelvic ring injuries has advantages of improving the accuracy of screw implantation and reducing radiation damage and the time of screw implantation.

Citation： CAO Wenhao, ZHU Zhengguo, QI Hongzhe, TANG Junjun, ZHANG Wei, LI Jiaqi, LI Shuangcheng, WANG Zhonghe, LI Changda, ZHOU Feng, LIU Haoyang, CHEN Hua, TANG Peifu. Early effectiveness of computer navigation system-assisted transiliac-transsacral screws placement for posterior pelvic ring injuries. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(9): 1049-1054. doi: 10.7507/1002-1892.202306092 Copy

1.	Failinger MS, McGanity PL. Unstable fractures of the pelvic ring. J Bone Joint Surg (Am), 1992, 74(5): 781-791.
2.	Keating JF, Werier J, Blachut P, et al. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma, 1999, 13(2): 107-113.
3.	Tile M. Acute pelvic fractures: Ⅰ. Causation and classification. J Am Acad Orthop Surg, 1996, 4(3): 143-151.
4.	中华医学会骨科学分会创伤骨科学组, 中华医学会骨科学分会外固定与肢体重建学组, 中华医学会创伤学分会, 等. 中国骨盆骨折微创手术治疗指南 (2021). 中华创伤骨科杂志, 2021, 23(1): 4-14.
5.	Matityahu A, Kahler D, Krettek C, et al. Three-dimensional navigation is more accurate than two-dimensional navigation or conventional fluoroscopy for percutaneous sacroiliac screw fixation in the dysmorphic sacrum: a randomized multicenter study. J Orthop Trauma, 2014, 28(12): 707-710.
6.	Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma, 2007, 21(1): 31-37.
7.	van den Bosch EW, van Zwienen CM, van Vugt AB. Fluoroscopic positioning of sacroiliac screws in 88 patients. J Trauma, 2002, 53(1): 44-48.
8.	Zwingmann J, Hauschild O, Bode G, et al. Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg, 2013, 133(9): 1257-1265.
9.	Zhao Y, Li J, Wang D, et al. Comparison of stability of two kinds of sacro-iliac screws in the fixation of bilateral sacral fractures in a finite element model. Injury, 2012, 43(4): 490-494.
10.	Gardner MJ, Routt ML. Transiliac-transsacral screws for posterior pelvic stabilization. J Orthop Trauma, 2011, 25(6): 378-384.
11.	Pishnamaz M, Wilkmann C, Na HS, et al. Electromagnetic real time navigation in the region of the posterior pelvic ring: An experimental in-vitro feasibility study and comparison of image guided techniques. PLoS One, 2016, 11(2): e0148199.
12.	Briem D, Windolf J, Rueger JM. Percutaneous, 2D-fluoroscopic navigated iliosacral screw placement in the supine position: technique, possibilities, and limits. Unfallchirurg, 2007, 110(5): 393-401.
13.	Al-Naseem A, Sallam A, Gonnah A, et al. Robot-assisted versus conventional percutaneous sacroiliac screw fixation for posterior pelvic ring injuries: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol, 2023, 33(1): 9-20.
14.	Chen H, Zhang Q, Wu Y, et al. Achieve closed reduction of irreducible, unilateral vertically displaced pelvic ring disruption with an unlocking closed reduction technique. Orthop Surg, 2021, 13(3): 942-948.
15.	Wu Y, Chen H, Zhou X, et al. Lateral compression type 2 pelvic fractures-a clinical study of fracture displacement measurement and closed reduction. Orthop Surg, 2022, 14(10): 2545-2552.
16.	陈华, 齐红哲, 朱正国, 等. 骨盆外架辅助复位联合通道螺钉固定治疗Tile C1型骨盆骨折. 中华创伤杂志, 2018, 34(10): 919-924.
17.	Gras F, Marintschev I, Wilharm A, et al. 2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries—a case series. BMC Musculoskelet Disord, 2010, 11: 153. doi: 10.1186/1471-2474-11-153.
18.	Araiza ET, Medda S, Plate JF, et al. Comparing the efficiency, radiation exposure, and accuracy using C-arm versus O-arm with 3D navigation in placement of transiliac-transsacral and iliosacral screws: A cadaveric study evaluating an early career surgeon. J Orthop Trauma, 2020, 34(6): 302-306.
19.	Guerin G, Laghmouche N, Moreau PE, et al. Iliosacral screwing under navigation control: Technical note. Orthop Traumatol Surg Res, 2020, 106(5): 877-880.
20.	Florio M, Capasso L, Olivi A, et al. 3D - Navigated percutaneous screw fixation of pelvic ring injuries-a pilot study. Injury, 2020, 51 Suppl 3: S28-S33.
21.	Han W, Zhang T, Su YG, et al. Percutaneous robot-assisted versus freehand S₂ iliosacral screw fixation in unstable posterior pelvic ring fracture. Orthop Surg, 2022, 14(2): 221-228.
22.	Madeja R, Pometlová J, Osemlak P, et al. Comparison of fluoroscopy and fluoroscopy-based 2D computer navigation for iliosacral screw placement: a retrospective study. Eur J Trauma Emerg Surg, 2022, 48(6): 4897-4902.
23.	Li N, Zhu Z, Xiao C, et al. The efficacy of “TiRobot” orthopaedic robot-assisted VS conventional fluoroscopic percutaneous screw fixation of the sacroiliac joint. Int Orthop, 2023, 47(2): 351-358.
24.	Passias BJ, Grenier G, Buchan J, et al. Use of 3D navigation versus traditional fluoroscopy for posterior pelvic ring fixation. Orthopedics, 2021, 44(4): 229-234.
25.	Stöckle U, Schaser K, König B. Image guidance in pelvic and acetabular surgery—expectations, success and limitations. Injury, 2007, 38(4): 450-462.
26.	Starr AJ, Walter JC, Harris RW, et al. Percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint (OTA Types 61-B2.2 and 61-B2.3, or Young-Burgess “lateral compression type Ⅱ” pelvic fractures). J Orthop Trauma, 2002, 16(2): 116-123.
27.	Berger-Groch J, Lueers M, Rueger JM, et al. Accuracy of navigated and conventional iliosacral screw placement in B- and C-type pelvic ring fractures. Eur J Trauma Emerg Surg, 2020, 46(1): 107-113.
28.	Boudissa M, Carmagnac D, Kerschbaumer G, et al. Screw misplacement in percutaneous posterior pelvic iliosacral screwing with and without navigation: A prospective clinical study of 174 screws in 127 patients. Orthop Traumatol Surg Res, 2022, 108(2): 103213.
29.	Zwingmann J, Konrad G, Kotter E, et al. Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure. Clin Orthop Relat Res, 2009, 467(7): 1833-1838.
30.	Theologis AA, Burch S, Pekmezci M. Placement of iliosacral screws using 3D image-guided (O-Arm) technology and Stealth Navigation: comparison with traditional fluoroscopy. Bone Joint J, 2016, 98-B(5): 696-702.

1. Failinger MS, McGanity PL. Unstable fractures of the pelvic ring. J Bone Joint Surg (Am), 1992, 74(5): 781-791.
2. Keating JF, Werier J, Blachut P, et al. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma, 1999, 13(2): 107-113.
3. Tile M. Acute pelvic fractures: Ⅰ. Causation and classification. J Am Acad Orthop Surg, 1996, 4(3): 143-151.
4. 中华医学会骨科学分会创伤骨科学组, 中华医学会骨科学分会外固定与肢体重建学组, 中华医学会创伤学分会, 等. 中国骨盆骨折微创手术治疗指南 (2021). 中华创伤骨科杂志, 2021, 23(1): 4-14.
5. Matityahu A, Kahler D, Krettek C, et al. Three-dimensional navigation is more accurate than two-dimensional navigation or conventional fluoroscopy for percutaneous sacroiliac screw fixation in the dysmorphic sacrum: a randomized multicenter study. J Orthop Trauma, 2014, 28(12): 707-710.
6. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma, 2007, 21(1): 31-37.
7. van den Bosch EW, van Zwienen CM, van Vugt AB. Fluoroscopic positioning of sacroiliac screws in 88 patients. J Trauma, 2002, 53(1): 44-48.
8. Zwingmann J, Hauschild O, Bode G, et al. Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg, 2013, 133(9): 1257-1265.
9. Zhao Y, Li J, Wang D, et al. Comparison of stability of two kinds of sacro-iliac screws in the fixation of bilateral sacral fractures in a finite element model. Injury, 2012, 43(4): 490-494.
10. Gardner MJ, Routt ML. Transiliac-transsacral screws for posterior pelvic stabilization. J Orthop Trauma, 2011, 25(6): 378-384.
11. Pishnamaz M, Wilkmann C, Na HS, et al. Electromagnetic real time navigation in the region of the posterior pelvic ring: An experimental in-vitro feasibility study and comparison of image guided techniques. PLoS One, 2016, 11(2): e0148199.
12. Briem D, Windolf J, Rueger JM. Percutaneous, 2D-fluoroscopic navigated iliosacral screw placement in the supine position: technique, possibilities, and limits. Unfallchirurg, 2007, 110(5): 393-401.
13. Al-Naseem A, Sallam A, Gonnah A, et al. Robot-assisted versus conventional percutaneous sacroiliac screw fixation for posterior pelvic ring injuries: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol, 2023, 33(1): 9-20.
14. Chen H, Zhang Q, Wu Y, et al. Achieve closed reduction of irreducible, unilateral vertically displaced pelvic ring disruption with an unlocking closed reduction technique. Orthop Surg, 2021, 13(3): 942-948.
15. Wu Y, Chen H, Zhou X, et al. Lateral compression type 2 pelvic fractures-a clinical study of fracture displacement measurement and closed reduction. Orthop Surg, 2022, 14(10): 2545-2552.
16. 陈华, 齐红哲, 朱正国, 等. 骨盆外架辅助复位联合通道螺钉固定治疗Tile C1型骨盆骨折. 中华创伤杂志, 2018, 34(10): 919-924.
17. Gras F, Marintschev I, Wilharm A, et al. 2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries—a case series. BMC Musculoskelet Disord, 2010, 11: 153. doi: 10.1186/1471-2474-11-153.
18. Araiza ET, Medda S, Plate JF, et al. Comparing the efficiency, radiation exposure, and accuracy using C-arm versus O-arm with 3D navigation in placement of transiliac-transsacral and iliosacral screws: A cadaveric study evaluating an early career surgeon. J Orthop Trauma, 2020, 34(6): 302-306.
19. Guerin G, Laghmouche N, Moreau PE, et al. Iliosacral screwing under navigation control: Technical note. Orthop Traumatol Surg Res, 2020, 106(5): 877-880.
20. Florio M, Capasso L, Olivi A, et al. 3D - Navigated percutaneous screw fixation of pelvic ring injuries-a pilot study. Injury, 2020, 51 Suppl 3: S28-S33.
21. Han W, Zhang T, Su YG, et al. Percutaneous robot-assisted versus freehand S₂ iliosacral screw fixation in unstable posterior pelvic ring fracture. Orthop Surg, 2022, 14(2): 221-228.
22. Madeja R, Pometlová J, Osemlak P, et al. Comparison of fluoroscopy and fluoroscopy-based 2D computer navigation for iliosacral screw placement: a retrospective study. Eur J Trauma Emerg Surg, 2022, 48(6): 4897-4902.
23. Li N, Zhu Z, Xiao C, et al. The efficacy of “TiRobot” orthopaedic robot-assisted VS conventional fluoroscopic percutaneous screw fixation of the sacroiliac joint. Int Orthop, 2023, 47(2): 351-358.
24. Passias BJ, Grenier G, Buchan J, et al. Use of 3D navigation versus traditional fluoroscopy for posterior pelvic ring fixation. Orthopedics, 2021, 44(4): 229-234.
25. Stöckle U, Schaser K, König B. Image guidance in pelvic and acetabular surgery—expectations, success and limitations. Injury, 2007, 38(4): 450-462.
26. Starr AJ, Walter JC, Harris RW, et al. Percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint (OTA Types 61-B2.2 and 61-B2.3, or Young-Burgess “lateral compression type Ⅱ” pelvic fractures). J Orthop Trauma, 2002, 16(2): 116-123.
27. Berger-Groch J, Lueers M, Rueger JM, et al. Accuracy of navigated and conventional iliosacral screw placement in B- and C-type pelvic ring fractures. Eur J Trauma Emerg Surg, 2020, 46(1): 107-113.
28. Boudissa M, Carmagnac D, Kerschbaumer G, et al. Screw misplacement in percutaneous posterior pelvic iliosacral screwing with and without navigation: A prospective clinical study of 174 screws in 127 patients. Orthop Traumatol Surg Res, 2022, 108(2): 103213.
29. Zwingmann J, Konrad G, Kotter E, et al. Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure. Clin Orthop Relat Res, 2009, 467(7): 1833-1838.
30. Theologis AA, Burch S, Pekmezci M. Placement of iliosacral screws using 3D image-guided (O-Arm) technology and Stealth Navigation: comparison with traditional fluoroscopy. Bone Joint J, 2016, 98-B(5): 696-702.

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Early effectiveness of computer navigation system-assisted transiliac-transsacral screws placement for posterior pelvic ring injuries

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