Artificial intelligence and CT-based 3D statistical modeling to assess transsacral corridors and plan implant positioning

[Orthopedics and trauma surgery in the digital age]

BACKGROUND

Digital transformation is shaping the future of orthopedics and trauma surgery. Telemedicine, digital health applications, electronic patient records and artificial intelligence play a central role in this. These technologies have the potential to improve medical care, enable individualized patient treatment plans and reduce the burden on the treatment process. However, there are currently challenges in the areas of infrastructure, regulation, reimbursement and data protection.

REALISING THE TRANSFORMATION

Effective transformation requires a deep understanding of both technology and clinical practice. Orthopedic and trauma surgeons need to take a leadership role by actively engaging with new technologies, designing new treatment processes and enhancing their medical skills with digital and AI competencies. The integration of digital skills into medical education and specialist training will be crucial for actively shaping the digital transformation and exploiting its full potential.

Speeding pelvic fracture fixation: CT scan with simultaneous 3-D pelvic reconstruction in the emergency department

INTRODUCTION

Contrast-enhanced computed tomography (CT) scans are usually needed in the emergency department (ED) to evaluate intra-abdominal injuries associated with pelvic fractures. Three-dimensional (3-D) images for pelvis reconstruction are also needed for planning surgical fixation after admission. This study investigates the advantages integrating a one-stage computed tomography (CT) scan with these two diagnostic modalities simultaneously to reduce the time to surgery and improve the outcomes of pelvic fracture fixation.

METHODS

A retrospective cohort study (2018-2021) of patients with pelvic fractures was performed. Patients were categorized into the one-stage CT group or the two-stage CT group, and propensity score matching was used to address biases. The outcome measures included time to surgical fixation, time to CT scan for 3-D pelvis reconstruction, and overall length of hospital stay.

RESULTS

Four hundred forty-four pelvic fracture patients who underwent definite surgical fixation were identified. Of those, 320 underwent a one-stage CT scan, while the remaining 124 underwent a two-stage CT scan. After well-balanced matching, those in the one-stage CT group had a significantly shorter time to surgical fixation than those in the two-stage CT group (4.6 vs. 6.8 days, p < 0.001). Even among critically ill patients necessitating intensive care unit (ICU) admission, the one-stage CT scan group had a shorter time to definitive surgical fixation (5.5 vs. 7.2 days, p = 0.002) and a shorter hospital stay (19.0 vs. 32.7 days, p = 0.006).

CONCLUSION

A one-stage contrast-enhanced CT scan combined with simultaneous 3-D pelvis reconstruction is promising for expediting surgical fixation in pelvic fracture patients. This innovative strategy may improve patient outcomes by facilitating timely surgical interventions and minimizing delays associated with additional CT scans.

Imaging, post-processing and navigation: Surgical applications in pelvic fracture treatment

Technical advancements of the past decade have led to massive improvements regarding imaging and visualization in trauma care. Digital imaging technology has fundamentally changed most processes in fracture management. However, the digital revolution in trauma surgery has just begun. Optical tracking navigation is currently the gold standard for positioning of implants for advanced applications in trauma surgery. Digital technology may enable the surgeon to achieve the same level of safety even in non-navigated placement of screws: We developed a new planning tool to transcript a preoperative into a semi-transparent "fluoroscopic like" image that can be identified intraoperatively and used as a map for the safe placement of sacro-iliac screws based on the "vestibule concept". In the future, development of artificial intelligence algorithms may provide features like automated segmentation of bone-fragments and other applications for a systematic fracture analysis to improve the standard of care in trauma surgery. Digital transformation has massive impact on diagnostics and surgical management of pelvic fractures. Improved visualization technology provides a better understanding of the surgical anatomy of the pelvis and may enable the surgeon to achieve greatest safety in percutaneous placement of screws even without using optical tracking navigation tools. The "para-axial fusion technique" is a useful tool to plan fluoroscopic views based on a 3D dataset prior to the surgery.

Failure of internal fixation of the anterior ring for unstable pelvic fractures, the experience of a single institute

Background

This study aimed to share our experience of anterior ring fixation failure for unstable pelvic fractures and propose corresponding treatment strategies.

Materials

From January 2009 to December 2018, 93 charts of patients with pelvic fractures were retrospectively reviewed. Patients with failure of the anterior ring internal fixation within 3 months after initial surgery were analyzed. Quality of reduction was evaluated using the Majeed scoring system. Patients aging ≥ 18 years, with unstable pelvic fractures, Tile classification type B and type C pelvic fractures, combined injury of other organs that did not affect the operation and without important neurovascular damage were included. The exclusion criteria included: (1) pathological fracture, or combined with pelvic bone tumor or severe osteoporosis; (2) femoral fracture and thoracolumbar fracture; (3) open pelvic fracture; (4) Morel-Lavallée injury; (5) complicated acetabular fracture. The quality of the reduction of the anterior pelvic ring injury was evaluated on the x-ray film using the Majeed scoring system.

Results

According to the Tile classification of fracture, there were 23 cases of type B1, 17 cases of type B2, 11 cases of type B3, 28 cases of type C1, 6 cases of type C2, and 8 cases of type C3. The duration from injury to pelvic internal fixation ranged from 5 to 28 days. Seven out of 93 patients experienced failure of internal fixation of the anterior pelvic ring within 3 months, including 2 patients fixed with an external fixator and 5 patients fixed with a plate. Five patients undergoing revision surgery were followed up for 6–36 months with an average of 18 months. According to Majeed’s score at the last follow-up in the 5 patients undergoing revision surgery, there were 2 cases of excellent, 2 cases of good, 1 case of fair. The excellent and good rate reached 80%.

Conclusion

The treatment of complicated unstable pelvic fractures requires performing internal fixation surgery within 2 weeks. It is necessary to make a preoperative plan and stabilize the posterior ring first, avoiding a single steel plate crossing the pubic symphysis.