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3D tibial plateu jurnal club final.pdf

  1. Intraoperative 3D imaging Maayan Kosovsky
  2. Introduction • Fluoroscopy - intraoperative analysis of fracture reduction and implant placement • Summation effect- concave shape of the tibial plateau • assessment of the complete articular surface may not be possible • Post operative CT needed to evaluate the surgical result
  3. Introduction • gold standard - post-operative CT • malreduction or implant misplacement, the patient might need secondary revision surgery • Intraoperative 3D imaging similar to CT detecting malreduction and implant malposition that were not visible in fluoroscopy
  4. Tibial Plateau • Tibial plateau fractures 1% of all fractures Treatment: • Conservatively - minimally displaced split or depressed fractures - low energy fracture stable to varus/valgus alignment - non-ambulatory patients - significant co-morbidites that preclude surgical intervention • Dislocated articular tibial plateau fractures, surgical management - gold standart
  5. Tibial Plateau • Frequently associated with soft tissue injury • Lateral plateau 70-80% bicondylar 10-30% medial plateau 10-20%
  6. AO/OTA classification
  7. Tibial Plateau- ORIF Indications • articular depression > 5-10 mm • condylar widening > 5mm • varus/valgus instability >10 deg • medial plateau fractures • bicondylar fractures Goals • restore alignment • normal condylar width • congruent articular surface • stable knee • minimize additional soft tissue trauma
  8. Study Aims • Evaluate intraoperative revision rate and reasons for revision following 3D imaging • Hypothesis- insufficient reduction or implant malposition may not be visible in fluoroscopy but can be visualized in intraoperative 3D imaging
  9. Materials and Methhods • Retrospective study • Patients who underwent surgery for type B or C tibial plateau fracture • Between August 2001 and December 2017 and whose results were verified using intraoperative 3D imaging
  10. Materials and Methhods The revisions were classified: • Improvement in reduction with articular step-offs of > 2 mm • Replacement of an intraarticular screw • Replacement of a screw with one of a different length • Other consequence
  11. Results • 559 fractures • Type B3 (37.4%), C3 (30.4%), B2 (15.9%), B1 (7.9%), C2 (4.5%), C1 (4.3%)
  12. Results 148 out of 559 cases (26.5%)- immediate intraoperative revision after using intraoperative 3D imaging • improved reduction result was achieved in 114 cases • Intraarticular screw was replaced in 5 cases • A different screw length was used in 21 cases (17 cases shorter screw, 4 cases longer screw)
  13. Results “Other consequences”: • 3 cases- an intraarticular bone fragment was removed which was not visible in fluoroscopy • 2 cases, an additional screw was inserted to support the reduction • 1 case, a plate projected proximally was corrected • 5 cases, the position of a screw was altered to achieve better fixation of a fragment • 2 cases, an additional defect was discovered which was not visible in fluoroscopy • 1 case, a lateral fragment could not be fixed and discarded • 1 case, it was found that a central fragment could not be reached via the lateral approach making an additional dorsal approach • 1 case, additional plate was necessary to achieve stabilization
  14. Discussion At least one revision based on 3D imaging in 26.5% of the cases • Improvement in reduction- 72.6% • AO/OTA- type C3 (multifragment)- 32.4%, B3 (split depression)- 27.5% • Detection of intraarticular bone fragments
  15. Discussion
  16. Discussion • 3D imaging offers an advantage over conventional imaging for all dislocated articular tibial plateau fractures • Improves the visualization of insufficient anatomical reduction, malpositioned implants, and intraarticular fragments • Immediate correction is possible • Subsequent surgery or an impaired clinical/ radiological outcome prevented
  17. Limitations • Restricted C- arm image can only display 12 × 12 × 12 cm • Lack of proof of the clinical benefit, only radiological consequences resulting from the intraoperative 3D imaging were examined • Case control analysis (ethical problem) • Consequences of a prolonged operation time of about 5 min per scan have not been investigated
  18. Conclusion • Correct alignment of the tibial plateau is difficult to evaluate using conventional fluoroscopy • Intraoperative 3D imaging appears to be beneficial for the analyzation of reduction and implant placement • If intraoperative 3D imaging is not available, a postoperative CT should be considered
  19. Take home message • Summation effects- conventional fluoroscopy is limited • 3D imaging offers an advantage over conventional imaging in articular fractures