Introduction: Fluoroscopy is routinely used for real-time intra-operative localization of patient anatomy and surgical instrument positioning. Using this radiographic information the orthopedic surgeon inserts different implants into bone. Despite its utility, however, fluoroscopy does have disadvantages. The most notable is potential occupational radiation exposure. Conventional fluoroscopy usually provides only one plane at a time, whereas at least two planes are needed for optimal placement of an implant. By combining a standard C-arm fluoroscopy with computer aided surgical technology, radiation exposure can be eliminated and four different planes can be visualized simultaneously. This study presents data of preliminary clinical experience using this new technology.

Material and methods: The Stealth Station Treatment Guidance Platform System by Medtronic was used. The calibration target was attached to a C-arm fluoroscope. The static reference arc which was attached to the patient and various surgical tools. All with affixed light emitting diodes (LEDs) which were seen by the Infra Red camera. After a short registration process in which the relevant anatomy images were acquired, the C-arm was withdrawn and the entry point to the operated anatomy was determined using the navigation capabilities of the system.

During a period of six months, 31 patients underwent different surgical procedures in which a guided wire was used for: percutaneous fixation of unstable pelvis and hip fractures (13 patients), inserting and locking of an intrameduallry nail (12 patients), inserting pedicular screws (2 patients), or removing foreign-bodies or internal fixations (4 patients). In all cases the placement of the hardware was approved by conventional fluoroscopy as well.

Results: Excellent correlation between the virtual fluoroscopic imaging and live fluoroscopy was observed, thus the placement of the wire in all cases was satisfactory and there was no need to change the position of the wire following the live fluoroscopic confirmation. The number of fluoroscopic buttoning was smaller than the average number in similar surgery using conventional fluoroscopy.

Discussion: According to our preliminary clinical experience it seems that virtual fluoroscopy offers several advantages over conventional fluoroscopy while providing acceptable targeting accuracy. Our impression is that its saves fluoroscopic radiation exposure and improves exactness of the procedure. However, since currently only one reference arc can be detected at a time by the guidance system it can be used only in a stable anatomical situations (such as non-displaced fractures or pedicular screw placements). The use of better-oriented surgical instrumentation and more than one reference point detection will significantly improve the clinical potential of this method.

Background: Osteoporotic tibial fractures may be a challenge both in diagnosis and treatment. The aim of treatment is obtaining joint congruity and normal alignment, joint stability, adequate soft tissue healing and functional range of motion. The goal is prevention of degenerative osteoarthritis. In the majority of cases the treatment of tibial plateau fractures consists of open reduction and internal fixation.

Objectives: The presentation of two aspects of the osteoporotic fracture – the insufficiency fracture and fixation of the fractures by a more appropriate method.

Patients: We present our experience with 7 cases treated during the past 2 years. Two of these cases presented with no story of trauma, normal X-rays and were diagnosed clinically and on CT and bone scanning. The other 5 cases resulted of minor trauma and operative treatment was in order, using a modified fixation technique – a small fragment plate.

Results: The patients suffering from fractures with normal X-rays suffered from insufficiency fractures and were treated conservatively. The patients suffering from depressed, split or comminuted fractures were treated by open reduction and internal fixation with a small fragment plate.

Discussion and Conclusion: Insufficiency fractures often are misdiagnosed as exacerbation of chronic metabolic or inflammatory diseases and a fracture is not suspected until intense augmentation of radionuclide is seen on bone scan. Screening of patients presenting wit non-traumatic knee pain has shown a prevalence insufficiency fractures of the tibial plateau between 3 to 8% of the cases. These cases may be much more common than we commonly presume.

The fractures in need of reduction and fixation of the plateau fracture involve raising the depressed articular fragment, the possible addition of bone graft augmentation and buttressing of the osteochondral fragment with a plate. These buttress plates may hold the cortical rim of the plateau but many times fail in maintaining the reduction of the intra-articular surface of the plateau. This again results in degenerative changes in the joint and pain.

Internal fixation of these fractures with small fragment plates may be a solution to this problem, as demonstrated by the 5 presented cases treated operatively. The plates are smaller in size and are held by more screws, which are more proximal to the articular surface. This way they allow better control and maintenance of the anatomic reduction and in combination with an a-traumatic dissection and less stress shielding effect, result in a low rate of local complications.

Four cases of osteomyelitis of the pelvis are reported to demonstrate the several clinical syndromes to which this disease can give rise. Extensive surgical drainage and antibiotic treatment led to recovery in all cases.

Split-thickness skin excision can be used as a one-stage procedure for the accurate diagnosis of flap viability and the immediate treatment of friction-avulsion injuries in severe open fractures. After cleaning the wound, the avulsed flap is temporarily sutured back to its original bed and a split thickness graft is taken from it and meshed to a 1:3 ratio. Surface dermal capillary bleeding then serves as an indicator of viability, clearly displaying a line for the excision of devascularized skin and correlating well with a concomitant fluorescein test. The wounds are re-opened and, after fixation of the fracture, the viable part of the flap is returned to its original bed and the remaining defects are covered with the meshed graft. We have treated 16 patients with extensive degloving injuries in this way, 15 needing only the single surgical procedure. All retained flaps survived, no other donor sites were needed and the split-thickness grafts took with 90% to 100% success.