Perkutane Reposition und Stabilisierung einer dislozierten Acetabulumfraktur

In the treatment of acetabular fractures, anatomic reconstruction of the joint is the primary aim. To achieve this, rather large approaches with approach-related morbidity are needed. Percutaneous stabilizations are still limited to nondisplaced or minimally displaced fractures. For displaced acetabular fractures there are percutaneous procedures described with intraoperative CT control, requiring that CT be available in the OR and posing a logistic challenge. The fluoroscope Siremobil Iso-C3D offers the possibility of displaying osseous structures with CT-like quality using a fluoroscopy technique. The case of a minimally displaced acetabular T-type fracture with a clear articular step in the weight-bearing area is presented. The percutaneous reduction and stabilization after intraoperative control of the reduction quality with the Siremobil Iso-C3D is demonstrated. Using the enhanced fluoroscopy technology with the ability to generate axial cuts and reconstructions comparable to CT clearly improves the reduction control also in acetabular surgery. Thus even displaced acetabular fractures can be reduced and stabilized percutaneously. Anatomic reconstruction of the joint remains the primary aim.     

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction.

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-C(3D)), 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-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.     

Computer assisted pelvic and acetabular surgery. Clinical experiences and indications

CT based navigation has been used in spine surgery since 1994. Several clinical studies could show an increase in precision compared to the conventional technique and thus nowadays the navigated pedicle screw placement is a routine procedure in many hospitals.Based upon the experience in spine surgery the CT based navigation module was used for percutaneous screw fixations in minimally displaced pelvic ring and acetabular fractures.After preclinical experimental trials the C-arm navigation was used for 19 screw fixations. The postoperative control of the screw position was performed with postop. X-ray and CT.Overall 23 of the 24 screws were placed correctly. In one SI screw the postoperative CT could reveal a ventral cortex perforation of the sacrum without any clinical symptoms.Based upon this limited clinical experience we see the indication for CT based navigation in minimally displaced acetabular fractures or in SI screw fixations in case of sacral dysplasia. The C-arm based navigation with adequate image quality is our method of choice for SI screw fixation in traumatic or degenerative instabilities, especially if reduction maneuvers are necessary.     

复杂髋臼骨折术中应用CT扫描的意义

 目的 探讨复杂髋臼骨折术中应用CT扫描的意义。方法 2008年 6月至 2010年 12月, 结合术中 CT监测治疗复杂髋臼骨折患者 14例, 男 9例, 女 5例;年龄 28~62岁, 平均 45.1岁。根据 Le tournel分型: 后柱加后壁骨折 2例, 横行加后壁骨折 4例, 野T冶形骨折 2例, 前柱加后半横行骨折 3例, 双柱骨折 3例。其中合并髋关节后脱位 3例, 股骨骨折 2例, 跟骨骨折 1例, L1骨折 1例, 坐骨神经损伤1例, 颅脑损伤 1例。术前采用 X线片、CT三维重建对骨折进行评估, 并使用三维影像处理软件进行术 前计划。手术复位后临时固定, 并使用野C冶型臂 X线机和 CT扫描三维重建评估复位质量, 对复位不满意 者重新复位。再次行术中 CT扫描三维重建检查内固定位置, 并与术前计划对照。结果 14例患者术中 平均接受 CT扫描 2.7次, 手术时间平均为 40.4 min, 平均接受放射量约为 47.2 mGy。术中再行复位者 4 例, 更改术前计划者 1例。术后采用 Matta影像学评价标准进行评估, 优 8例, 良 3例, 差 3例;优良率为 78.6%。结论 术中 CT扫描三维影像监测增加了手术时间和患者放射线暴露, 在评估复位质量方面与 传统野C冶型臂 X线机相似, 根据术中 CT扫描三维重建结合术中情况实施手术与术前计划基本吻合。在 术前使用 X线片、CT三维重建对髋臼骨折进行仔细评估的前提下, 术中使用 CT三维影像监测是否有 利于提高手术成功率减少手术并发症尚有待进一步商榷。     

Arthroscopic-Assisted Reduction and Percutaneous External Fixation of Lateral Condyle Fractures of the Humerus

Lateral condyle fractures in children are the second most common fracture about the elbow. Anatomic reduction of intra-articular displacement is considered a priority. Most experts agree that the treatment of choice of mildly displaced (>2 mm) lateral condyle fractures is open reduction–internal fixation or intraoperative arthrography followed by closed reduction and percutaneous pinning. In this report we described an alternative approach using closed arthroscopic-assisted reduction. Arthroscopy was performed by use of a 30°, 4.5-mm arthroscope through a proximal anteromedial portal with no pump, and a proximal anterolateral portal was created for instrumentation. The fracture line was easily visualized after blood, fibrin, and loose articular debris were irrigated from the joint. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and via rotation until there was no step in the articular cartilage. Two lateral Kirschner wires were placed percutaneously, which result in firm fixation of the fracture. We think that the advantages of arthroscopy are further superior to intraoperative arthrography because arthroscopy not only allows for better anatomic reduction and visualization with minimal surgical trauma and less radiation time but also provides a valid diagnostic and treatment alternative for associated injuries.     

Verletzungen des Azetabulums

Anatomic reduction of the articular surface is essential in the definitive therapy of acetabular injuries. The required surgical approaches with extensive and deep exposure of the adjacent soft tissue may cause additional iatrogenic trauma. Computer-aided navigation based on 2D and 3D fluoroscopy is increasingly being applied for successful percutaneous screw fixation. Non-dislocated or minimally dislocated but unstable fractures are particularly suitable for navigation. The advantages of computer-assisted navigation are the improved accuracy of screw placement and reduced radiation exposure as well as protection of the soft tissue. Therefore, percutaneous navigated screw fixation is a promising alternative to conventional operative procedures in selected acetabular fractures considering the primary goals of anatomic reduction and rigid fixation allowing early exercises.     

Periazetabuläre Navigation

Following a period of conservative treatment of acetabular fractures in the past, the use of classifications and defined acetabular surgery indications was introduced because of an increasing number of extended surgical approaches for operative stabilization of acetabular fractures. This development has enabled minimally invasive procedures using three-dimensional (3D) visualization and navigation techniques in the operating room (OR), with the expectation of reduced intraoperative morbidity and optimized surgical precision. Most common in acetabular navigation is 3D C-arm-based navigation, which has enabled new techniques in combination with other modern OR systems. In special cases, techniques based on computed tomography and 2D C-arms are still used.     

Improved Therapy of Calcaneal Fractures by Intraoperative 3D-Fluoroscopy and Locked-Screw Plate Fixation

Abstract The operative therapy of intraarticular fractures of the calcaneus is now an established surgical standard. The aim is an accurate reduction of the fracture with reconstruction of the Boehler’s angle, the length and the subtalar joint. Intraoperative 3D-fluoroscopy with the Siremobil ISO-C-3D^? mobile C-arm radiography system is a valuable assistant for the accurate reconstruction of these anatomical structures. Remaining incongruities can be recognized and corrected intraoperatively. The achieved reduction can be safely fixed by the advantages of an internal fixator (lockedscrew plate interface). In the period from October 2002 until October 2004, we operated 58 patients with intraarticular fractures of the calcaneus by means of anatomical reduction, an internal plate fixator under intraoperative control of 3D-fluoroscopy. In 22 cases the intraoperative 3D-fluoroscopy uncovered remaining incongruity over 1 mm, which could be corrected. The Boehler’s angle was raised on average by 16°. In no case a secondary dislocation of the fracture was seen.     

Computer-assisted knee surgery, what can we expect?

Navigation systems for operative assistance in knee joint surgery have been established in the last 5 years. Among the large number of variable systems, the image-free kinematic systems have won widespread acceptance. The C-arm based systems are not superior to the image-free systems. The CT-based systems are advantageous in completely destroyed joints (with marked joint erosion) or advanced congenital or traumatic deformities. The intraoperatively-performed Iso-C (3D) technique presents data sets in CT-quality, but because of its small data volume currently is limited to the reconstruction of articular surfaces following fractures. The use of image-free navigation in resurfacing knee arthroplasty is in the meantime beyond controversy whereby deviations in the mechanical axis from normal values can be significantly reduced. For high tibial osteotomies navigation modules will be soon available for marketing. However, with these modules, intraoperative imaging is indispensable, but it will be image-free in the future. The early clinical results are promising. Cruciate ligament navigation is not yet a clinical standard be-cause of the considerable associated time expenditure. The appropriate modules are still under development.     

Image guidance in pelvic and acetabular surgery--expectations, success and limitations

During the last decade navigation techniques in pelvic and acetabular surgery have been described. Nowadays, available techniques include CT-based navigation, 2D C-arm navigation and 3D C-arm navigation. The main indication is the navigated percutaneous SI screw fixation, but acetabular screw fixations are also reported. In this article, based upon a literature review and our own clinical experiences, the indications for and limitations of navigated techniques in pelvic and acetabular surgery are described.     

Is there a role for percutaneous pelvic and acetabular reconstruction?

The primary goal in the treatment of pelvic fractures is the restoration of haemodynamic stability. The secondary goal is the reconstruction of stability and symmetry of the pelvic ring. Percutaneous reconstruction can only be accepted if these goals are met. The type of definitive surgery is dependent of the degree of instability of the anterior and posterior pelvic ring. Retrograde transpubic screw fixation of pubic rami fractures is a good alternative to external fixation or plate and screw osteosynthesis. The technique of screw placement and image intensifier control is explained. Internal fixation of pure sacroiliac dislocations, fracture-dislocations of the sacroiliac joint and sacral fractures can be fixed with sacroiliac screws, placed percutaneously. Reduction of the fracture or dislocation is performed closed, or open if anatomy cannot be restored in a closed manner. The primary goal in the treatment of acetabular fractures is to restore anatomy. Reduction comes before fixation. The goal of minimising approaches cannot be more important. In most cases open reduction will be necessary to achieve anatomical reconstruction. Only the experienced acetabular surgeon will be able to decide when and how he can restore anatomy through a less invasive approach or with a percutaneous procedure. The anterior column screw can be inserted through a separate incision in addition to a Kocher-Langenbeck approach. It is the same screw as the retrograde transpubic screw but placed in the opposite direction. The posterior column screw is placed percutaneously from the lateral cortex of the ilium in the direction of the posterior column. Techniques of placement of both screws are demonstrated. Open reduction and internal fixation remains the standard of care in stabilisation of pelvic and acetabular fractures. Only the experienced surgeon will be able to judge if percutaneous procedures can be an alternative or a useful additive to conventional techniques.     

Primäre Schulterendoprothetik nach Trauma

Indications for primary shoulder prosthesis in displaced four-part fractures has decreased in recent years due to new techniques in fracture reconstruction using angle-stable plate osteosynthesis. The challenge of four-part fractures with an intact head fragment is the anatomic reconstruction and fixation of the tuberosities. Using a fracture prosthesis does not solve this problem. In complex head-split fractures arthroplasty is indicated, but the difficulty of tuberosity refixation and healing remains. New prosthetic designs improve tuberosity fixation and healing, as well as correct placement and orientation of the prosthesis. Anatomic fracture reconstruction should always be the goal and this goal should not be abandoned too easily.     

The Role of Surgical Hip Dislocation in the Treatment of Acetabular and Femoral Head Fractures

Abstract Background and Purpose: Surgical hip dislocation by trochanteric flip osteotomy facilitates access to acetabular and femoral head fractures. Furthermore, it allows evaluation of cartilage damage and vascularity of the femoral head. In this study the potential benefits of this procedure for improved fracture management and for prognostic assessment were investigated. Patients and Methods: From July 1997 to October 1999, 20 selected patients with displaced acetabular fractures (n = 12), femoral head fractures (n = 7), or combined injuries (n = 1) were included. Inclusion criteria for acetabular fractures were either displaced posterior wall fragments with cranial extension or complex acetabular fractures involving a displaced transverse fracture line. Open reduction and fixation of either complex acetabular fractures or femoral head fractures were carried out through Kocher-Langenbeck approach, trochanteric flip osteotomy, and complete surgical hip dislocation. Additionally, the extent of cartilage destruction and femoral head perfusion were assessed. Results: Anatomic reduction ( 1 mm displacement) of acetabular fractures was achieved in 69% of patients and good reduction ( 3 mm) in 31%. In patients with acetabular fractures, severe cartilage destruction of the acetabulum was found in 38% and of the femoral head in 15%, while patients with isolated femoral head fractures revealed severe cartilage damage of the femoral head in 57%. Arterial bleeding from the femoral head, tested by drilling, was observed in all patients. Secondary dislocation of the trochanteric osteotomy occurred in one patient and made refixation necessary. Patients were reexamined at least 2 years after intervention. 77% of patients with acetabular fractures and all patients with femoral head fractures showed good or excellent results after 32.6 ± 6.1 months according to the functional score of DAubigné & Postel. Conclusion: Surgical hip dislocation allows adequate reconstruction of complex acetabular and femoral head fractures and intraoperative evaluation of local cartilage damage and femoral head perfusion.     

髋臼骨折的手术治疗

目的：评价手术治疗髋臼移位骨折的效果。方法：总结对38例有移位髋臼骨折手术治疗的经验。根据骨折类型选用髂腹股沟入路、Kocher-Langenbeck入路、延长髂股入路，复位后用骨盆钢板和可吸收钉固定。结果：38例中22例（57.9%），完全复位，8例（21.05%）满意复位，8例（21.05%）复位不满意。30例获得随访，平均随访时间2.5年。根据Matta评分标准：优9例（30％),良13例（37％），一般6例（20％）。差4例（13％）。结论：对于髋臼骨折，联合应用三个方向的X片和CT扫描，准确诊断，尽早予以解剖复位，牢固固定，骨折愈合后负重运动。     

The use of a 3D-printed personalised drill guide for posterior column lag screw fixation in displaced transverse acetabular fracture: A case report

Introduction and importanceAnterior column plate combined with posterior column screws have been effectively used for treatment of displaced transverse acetabular fractures. This article presents the use of 3D-printed technology for customising a guide template to appropriately place posterior column screw.Case presentationA 50-year-old female suffered displaced juxtatectal fracture of the right acetabulum. A personalised guide for antegrade posterior column screw placement was designed based on the data of her pelvic CT-scan. This guide and a prototype of her right acetabulum - created by mirroring the intact left acetabulum - were 3D-printed for preoperative evaluation and pre-contouring of reconstruction plate. Modified Stoppa approach and additional lateral window were used for direct reduction, anterior column plate and posterior column lag screw fixation. Post-operative CT-scan showed good reduction and nearly ideal screw position.Clinical discussionAnterior column plate and antegrade posterior column screw could provide joint stability and early mobilisation for displaced transverse acetabular fractures. However, determination of optimal entry point, direction and length for screw insertion is still technically demanding. The 3-D reconstruction images of hemipelvic specimen allowed us to identify the safe bone corridor, design a drill guide to put the proper guide pin and conduct preoperative trial. All those resulted in appropriate real screw fixation with reduction of soft tissue damage, X-ray exposure and time of operation.ConclusionThe use of 3D-printed personalised guide for posterior column screw fixation is a promising alternative option for treatment of displaced transverse acetabular fracture where 3D-navigation system is not available.     

Early postoperative acetabular discontinuity after total hip arthroplasty

Periprosthetic acetabular fracture is a rare complication after total hip arthroplasty (THA). However, we have treated 2 patients with acute postoperative acetabular discontinuity that occurred 2 and 3 weeks after primary THA. Both fractures were in elderly osteoporotic female patients with minimal trauma and may have developed from unrecognized intraoperative fractures. Pelvic stability was restored with acetabular revision using medial morselized bone grafting and a cemented reconstruction cage. This report demonstrates that early postoperative periprosthetic acetabular discontinuity after THA is a risk in elderly patients with severe osteoporosis and that salvage of acetabular fixation can be achieved with cemented cage reconstruction and medial morselized bone grafting.     

3-D imaging with a mobile surgical image enhancement equipment (ISO-C-3D). Initial examples of fracture diagnosis of peripheral joints in comparison with spiral CT and conventional radiography

To analyze a prototype mobile C-arm image amplifier (Iso-C3D) in the evaluation of different joint fractures of the upper and lower limbs using multiplanar reconstruction (MPR). Different cadaver joint specimens (n = 14) were examined with a prototype (Iso-C3D, Siemens AG, Erlangen, Germany), plain radiographs (CR), and spiral computed tomography (CT). The motorized C-arm provides fluoroscopic images during a 190 degrees orbital rotation computing a 119-mm data cube. These three-dimensional data sets yielded MPR images, which were evaluated by two readers for the detection and extent of fracture lines. Initial data show that fractures were easily depicted and correctly classified on MPR images with the Iso-C3D and that there was no difference between the Iso-C and CT in the detection of fractures. The preliminary results suggest a remarkably good detection of joint fractures with the Iso-C3D. Studies in an adequate number of patients are required to elucidate whether these promising results can also be obtained in a clinical setting.     

Minimal-invasive Osteosynthese von Kalkaneusfrakturen

Objective

Anatomic reduction of displaced calcaneal fractures with minimal soft tissue alteration.

Indications

Extra-articular and selected intra-articular calcaneal fractures (simple fracture pattern: Sanders type?II, critical soft tissue conditions, contraindications to open reduction), temporary stabilization of complex injuries or polytraumatized patients.

Contraindications

Impossible percutaneous reduction and fixation.

Surgical technique

Gross reduction of the main fragments is achieved with a Schanz screw introduced percutaneously into the tuberosity fragment. Fine reduction is obtained through percutaneous manipulation of the fragments wit Kirschner wires, Steinmann pins, sharp and smooth elevators via stab incisions. Anatomic reduction of the subtalar joint is controlled arthroscopically in cases of displaced intra-articular fractures. Fixation is achieved with screws introduced percutaneously.

Postoperative management

Early range of motion exercises of the ankle and subtalar joints are initiated the first postoperative day. Beginning on postoperative day?2, patients are mobilized with partial weight bearing for 6–8?weeks. As soon as the edema has subsided, patients are encouraged to wear their own shoes.

Results

Between 1998 and 2008, 68?patients were treated with definite percutaneous fixation for displaced calcaneal fractures. In 37?patients with intraarticular fractures (Sanders types?IIA and IIB), anatomic joint reduction was verified with subtalar arthroscopy. No soft tissue-related complications were observed. Thirty-five patients were followed for a minimum of 2?years postoperatively, the average was 5?years postoperatively. Subjectively, 33 of 35?patients were satisfied with the clinical outcome. The AOFAS Hindfoot Score averaged 90.7 (range 64–100) at a mean of 5?years after surgery. Percutaneous screw fixation of calcaneal fractures is associated with minimal soft tissue traumatization and low complication rates. It allows early rehabilitation and excellent results with proper patient selection. With intra-articular fractures, proper reduction of the articular surface has to be confirmed intraoperatively.     

手术治疗移位髋臼骨折31例

目的探讨移位髋臼骨折的手术方法和疗效。方法回顾分析2003年5月至2009年7月在我院治疗的31例移位髋臼骨折,按Letournel分类方法而采用不同手术入路使用重建钢板及螺钉内固定治疗后壁骨折6例,后柱骨折4例,前壁骨折2例,前柱骨折3例,横行骨折6例,横行伴后壁骨折3例,双柱骨折2例,后壁伴后柱骨折3例,T型骨折2例。结果所有病例获3-36个月随访,按美国矫形外科评价髋关节功能的方法进行评价,优20例,良6例,可3例,差2例,优良率为83.8%。结论术前结合X线CT正确判断髋臼骨折类型,选择合适的手术入路,使骨折复位精确,结合重建钢板和螺钉固定,可获得良好的治疗效果。     

术中即时三维导航在后凸成形术中的应用

目的 探讨应用术中即时三维导航行后凸成形术(PKP)治疗骨质疏松性椎体压缩性骨折的方法、疗效及适应证的选择. 方法 2006年4月至2009年8月在术中即时三维导航引导下行经皮穿刺PKP 15例(44个椎体).比较手术前、后视觉模拟法(VAS)评分、伤椎前后缘高度及伤椎Cobb角变化. 结果 15例患者术后第1～2天均可佩戴胸腰骶支具下地活动,VAS评分、伤椎前后缘高度及Cobb角均较术前明显恢复,差异均有统计学意义(P<0.05).术中穿刺针及工作通道置入位置准确,未发现椎弓根穿破的患者,围手术期无肺柃塞、神经功能障碍等并发症发生.所有患者随访3～14个月,平均7.1个月;未次随访X线片示骨折愈合良好,未发现手术节段椎体再次塌陷. 结论应用术中即时三维导航行PKP可以明显提高手术的精确度和安全性,简化手术步骤,减少辐射的危害和手术并发症,疗效肯定.行PKP治疗骨质疏松性椎体压缩性骨折时,如存在多发骨折(≥3个椎体)、中上胸椎骨折、骨折压缩严重或严重骨质疏松等情况,应考虑应用术中即时三维导航进行辅助.