FLUORO-NAVIGATION IN ORTHOPAEDIC TRAUMA SURGERY

Abstract

In orthopaedic trauma surgery, X-ray fluoroscopy is frequently employed to monitor fracture reduction and to guide surgical procedures where implants are inserted to fix the fractures. Fluoro-navigation is the application of real-time navigation on intraoperatively acquired fluoroscopic images to achieve the same goals. The theoretical advantages of fluoro-navigation are:

1. Minimising exposure to X-ray on surgeons, operating room personells and patients,

2. Accurate positioning of implants,

3. Expanding the application of minimally invasive surgery,

4. Shortening the operation time

Fluoro-navigation is particular indicated in orthopaedic trauma as the fracture fragments are mobile and the orientations are not fixed before surgery. At this time, many procedures that require intraoperative fluoroscopic control can now be done with fluoro-navigation. These procedures include:

1. Fixation of femoral neck fractures with percutaneous cannulated screws,

2. Intramedullary locked nails for long bone fractures,

3. Intramedullary fixation of trochanteric fractures

4. Percutaneous fixation of sacro-iliac fractures dislocations

5. Percutaneous fixation of iliac wing fractures

6. Percutaneous fixation of acetabulum fractures

7. Insertion of Ilizarov tension wires for complex articular fractures

8. Many percutaneous fixation procedures that need fluoroscopic controls

Since 2001, we have been using fluoro-navigation orthopaedic trauma surgery. 535 different procedures of operative treatment of fractures were carried out. These operative procedures included. Operation, amount, success rate:

Femoral neck fractures, 65, 100%, Gamma nailing, 172, 100%, Femoral locked nails, 77, 98.5%, Tibial locked nails, 53, 100%, Sacro-iliac screws, 45, 95.1%, Pelvic acetabular fractures, 29, 96.1%, Ilizarov tension wires, 13, 100%, Percutaneous screws, 18, 100%, Distal locking without X-ray, 15, 100%, 3-D Navigation, 48 92.7%.

Our clinical experience has confirmed the advantages and the extended applications of this technique benefited many of our patients by enhancing minimally invasive technique in orthopaedic trauma surgery, better implant position and significantly decreasing the radiation of the fluoroscopy (p< 0.05). We have modified the operative procedures in order to adapt better with the fluoro-navigation procedures. We also worked with the industrial partners to design specific instruments as well as modified the existing surgical instruments to facilitate the fluoro-navigation procedures. Most of the failure were due to poor quality fluoro-images, unstable operating system and poorly adapted surgical instruments in the early phase of the applications.

Further improvement is expected in the system on the hardware and software for quicker image acquisition with improved quality, accurate and precise registration, increase interactivities and adaptation of surgical instruments as well as implants. There is a great need for the development of dedicated surgical instruments for orthopaedic trauma sugary in line with the further improvement of the navigation system. With the establishment of image libraries for implants and skeleton, further minimising the need for standard fluoroscopy will be possible. The combination of 3-D fluoroscopy and the navigation will improve percutaneous fixation of articular fractures. At the time, it is only possible to navigate the images obtained during the operation after fracture reduction or manipulation is completed. The possibility to navigate on each individual fracture fragment will extend the technique even more to real-time fracture reduction.

The fluoro-navigation system will also play an important role in surgical training as well as assessment in the virtual surgical environment. We also developed specific training models for fluoro-navigation for preoperative training and practice of standard procedures. This will help to promote further application of fluoro-navigation in orthopaedic trauma.

The recognition of its clinical significance will help to stimulate more research and thus encourages industries to devote more resources in the development of fluoro-navigation for orthopaedic trauma.