Intraoperative Computed Tomography in Orthopaedic Trauma Surgery

Abstract

Background When using mobile 3D C-arms, impairments in image quality occur due to artefacts caused by metal implants as well as to the limited field of view. To avoid these restrictions, special computed tomography devices were designed, in order to improve image quality and to meet requirements for intraoperative usage.

Objectives To analyse practicability and benefits of a mobile intraoperative CT device (Airo, Brainlab, Munich, Germany) on the basis of several parameters that were obtained during a 40-month period.

Materials and Methods All procedures that were performed with usage of intraoperative CT between January 2017 and April 2020 were analysed with respect to anatomical region, count of scans, duration of scans, consequences drawn from the scans and use of navigation.

Results 354 CT-scans were performed in 171 patients (mean 2.07 [1–6] scans per procedure). 47.81% of the procedures were spinal, 52.19% affected the pelvis. 83% of the procedures were navigated. In 22% of patients, improvement in implant placement or reduction was achieved; in most patients (55%), a guidewire for pedicle screws was corrected. The mean scan duration was 10.33 s (3.54–21.72).

Conclusions Use of intraoperative CT was reliable and helpful. Integration in OR standards requires more effort than mobile 3D C-arms. Image quality was outstanding for intraoperative conditions and allowed proper assessment of implant placement and reduction in all cases. Due to the high financial outlay of the system and the good image quality of 3D C-arms in the extremities, we assume that this procedure can be applied in intraoperative CT in traumatological cases in spinal and pelvic surgery in high-level trauma centres.

Zusammenfassung

Hintergrund Bei der Anwendung mobiler 3-D-C-Bögen bestehen Einschränkungen hinsichtlich der Bildqualität, insbesondere durch Artefaktbildung und die limitierte Größe des 3-D-Volumens. Um diese Limitationen zu umgehen, wurden spezielle mobile intraoperative Computertomografen (iCT) konstruiert, die sowohl eine Verbesserung der Bildqualität sowie ein größeres „Field of View“ bieten als auch den Anforderungen eines intraoperativen Einsatzes gerecht werden sollen.

Ziel der Arbeit Praktikabilität und Bildqualität eines Systems zur mobilen intraoperativen CT-Diagnostik (Airo, Brainlab, München) werden anhand verschiedener Parameter über einen Zeitraum von 40 Monaten evaluiert.

Material und Methoden Alle operativen Eingriffe, die im Zeitraum zwischen Januar 2017 und April 2020 unter Anwendung der iCT erfolgten, wurden hinsichtlich der Parameter Operationsgebiet, Anzahl der Scans, Scandauer, Konsequenz aus dem Scan und Verwendung eines Navigationssystems ausgewertet.

Ergebnisse 354 CT-Scans von 171 Patienten wurden ausgewertet (durchschnittlich 2,07 [1–6] Scans pro Eingriff). Hierbei erfolgten 47,81% der Eingriffe an der Wirbelsäule und 52,19% am Becken. 83% (42–100) der Eingriffe erfolgten navigiert. In 22% der Eingriffe wurde nach einem Scan eine Maßnahme durchgeführt, am häufigsten (55%) erfolgte hierbei die Korrektur eines Führungsdrahts an der Wirbelsäule. Die durchschnittliche Scandauer betrug 10,33 s (3,54–21,72).

Diskussion Die Anwendung war zuverlässig und hilfreich. Der Prozess der Integration in die Abläufe ist aufwendiger als bei der Verwendung mobiler 3-D-C-Bögen. Die Bildqualität ist für intraoperative Bedingungen hervorragend und erlaubt in allen Fällen eine sichere und eindeutige Beurteilung der Situation. Aufgrund des hohen intraoperativen Aufwands sowie der hohen Investitionskosten des Systems bei ebenfalls guter Bildqualität mobiler 3-D-C-Bögen in der Extremitätenchirurgie ist die traumatologische Anwendung der iCT hauptsächlich in der operativen Therapie von Körperstammverletzungen in großen Traumazentren zu sehen.

Key words

intraoperative imaging - intraoperative computed tomography - 3D imaging - spine trauma - pelvic trauma

Schlüsselwörter

intraoperative Bildgebung - intraoperative Computertomografie - 3-D-Bildgebung - Wirbelsäulentrauma - Beckentrauma

^* This article is a republished version of: Keil H, Vetter SY, Grützner PA, Franke J. Intraoperative Computed Tomography in Orthopaedic Trauma Surgery. Z Orthop Unfall 2022;160(4):407–413.

Publication History

Article published online:
09 January 2025

• References

• 1 Rommens PM. Paradigm shift in geriatric fracture treatment. Eur J Trauma Emerg Surg 2019; 45: 181-189
• 2 Rommens PM. Focus on geriatric trauma. Eur J Trauma Emerg Surg 2019; 45: 179-180
• 3 Höch A, Pieroh P, Gras F. et al. Age and “general health”–beside fracture classification–affect the therapeutic decision for geriatric pelvic ring fractures: a German pelvic injury register study. Int Orthop 2019; 43: 2629-2636
• 4 Piétu G, Ehlinger M. Minimally invasive internal fixation of distal femur fractures. Orthop Traumatol Surg Res 2017; 103 (1 Suppl.): S161
• 5 Toogood P, Huang A, Siebuhr K. et al. Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis. Injury 2018; 49 (Suppl. 01) S19-S23
• 6 Van Tiggelen R. Since 1895, orthopaedic surgery relies on x-ray imaging: a historical overview from discovery to computed tomography. Acta Orthop Belg 2001; 67: 317-329
• 7 Stengel D, Wich M, Ekkernkamp A. et al. Intraoperative 3-D-Bildgebung: Diagnostische Genauigkeit und therapeutischer Nutzen. Unfallchirurg 2016; 119: 835-842
• 8 Moon SW, Kim JW. Usefulness of intraoperative three-dimensional imaging in fracture surgery: A prospective study. J Orthop Sci 2014; 19: 125-131
• 9 von Recum J, Wendl K, Vock B. et al. Die intraoperative 3D-C-Bogen-Anwendung. Unfallchirurg 2012; 115: 196-201
• 10 Eagleton MJ. Intraprocedural imaging: Flat panel detectors, rotational angiography, FluoroCT, IVUS, or still the portable C-arm?. J Vasc Surg 2010; 52 (4 Suppl.): 50S-59S
• 11 Keil H, Beisemann N, Schnetzke M. et al. Intraoperative assessment of reduction and implant placement in acetabular fractures-limitations of 3D-imaging compared to computed tomography. J Orthop Surg Res 2018; 13: 78
• 12 Weir VJ, Zhang J, Bruner AP. Dosimetric characterization and image quality evaluation of the AIRO mobile CT scanner. J Xray Sci Technol 2015; 23: 373-381
• 13 Fujimori T, Iwasaki M, Nagamoto Y. et al. Reliability and Usefulness of Intraoperative Three-Dimensional Imaging by Mobile C-Arm With Flat-Panel Detector. J Spinal Disord Tech 2013; 30: E64-E75
• 14 Xiao R, Miller JA, Sabharwal NC. et al. Clinical outcomes following spinal fusion using an intraoperative computed tomographic 3D imaging system. J Neurosurg Spine 2017; 26: 628-637
• 15 Beck M, Rotter R, Gradl G. et al. Reliability and consequences of intraoperative 3D imaging to control positions of thoracic pedicle screws. Arch Orthop Trauma Surg 2012; 132: 1371-1377
• 16 Gupta R, Cheung AC, Bartling SH. et al. Flat-panel volume CT: fundamental principles, technology, and applications. Radiographics 2008; 28: 2009-2022
• 17 Kraus M, Fischer E, Gebhard F. et al. Image quality and effective dose of a robotic flat panel 3D C-arm vs. computed tomography. Int J Med Robot 2016; 12: 743-750
• 18 Keil H, Beisemann N, Schnetzke M. et al. First experiences with the Airo mobile intraoperative CT scanner in acetabular surgery-An analysis of 10 cases. Int J Med Robot 2019; 15: e1986
• 19 Privalov M, Mohr M, Swartman B. et al. Evaluation of Software-Based Metal Artifact Reduction in Intraoperative 3D Imaging of the Spine Using a Mobile Cone Beam CT. J Digit Imaging 2020; 33: 1136-1143
• 20 Privalov M, Beisemann N, Swartman B. et al. First experiences with intraoperative CT in navigated sacroiliac (SI) instrumentation: An analysis of 25 cases and comparison with conventional intraoperative 2D and 3D imaging. Injury 2020;
• 21 Keil H, Luxenhofer M, Vetter SY. et al. Evaluation of image quality and assessability of a new flat-panel 3D C-arm compared to mobile and fixed computed tomography in posterior spinal fixation. Int J Med Robot 2020;
• 22 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. J Orthop Trauma 2014; 28: 707-710
• 23 Thakkar SC, Thakkar RS, Sirisreetreerux N. et al. 2D versus 3D fluoroscopy-based navigation in posterior pelvic fixation: review of the literature on current technology. Int J Comput Assist Radiol Surg 2017; 12: 69-76
• 24 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: 1257-1265