The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue Supplement 1

Section III: Morphology, Intraoperative Imaging, and Image Processing | February 01, 2009

Utility of Intraoperative Three-Dimensional Imaging at the Hip and Knee Joints with and without Navigation

Tobias Hüfner, MD¹; Timo Stübig, MD¹; Musa Citak, MD¹; Thomas Gösling, MD¹; Christian Krettek, MD¹; Daniel Kendoff, MD¹

¹ Trauma Department, Hannover Medical School, Carl Neubergstrasse 1, 30625 Hannover, Germany. E-mail address for T. Hüfner: huefner.tobias@mh-hannover.de

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Feb 01;91(Supplement 1):33-42. doi: 10.2106/JBJS.H.01441

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Abstract

Intraoperative three-dimensional imaging in orthopaedic trauma care has achieved greater importance over the last few years in some specialized hospital centers. For various types of peripheral-extremity trauma, clinical studies have confirmed, on the basis of three-dimensional information, an intraoperative revision rate ranging from 7% to 19%. Three-dimensional C-arm imaging may be used to achieve adequate intraoperative information about the quality of fracture reduction, residual steps, and correct implant placement, and this technique has been described for use in both the hip joint (for acetabular fractures, isolated femoral head [Pipkin-type] fractures, three-dimensional navigated sacroiliac screw or acetabular column screw placements, and, less frequently, for navigated drilling of tumors or osteochondral lesions) and the knee joint (for tibial plateau fractures, complex distal femoral condylar fractures, and navigated targeting of osteochondral lesions in combination with the use of preoperative magnetic resonance imaging scans). Major limitations of this technology include increased intraoperative time requirements, limited image quality compared with that of computed tomographic scans, cost, specific positioning techniques, and the need for radiolucent operating-room tables. Although prospective studies have yet to be conducted, the ways in which the surgeon will benefit from the use of intraoperative three-dimensional imaging are apparent, but indications for combined three-dimensional C-arm navigated procedures at the hip and knee joint are still limited. Future directions may include the use of digital flat-panel detectors and even robotic-controlled C-arm motion.

Figures in this Article

Introduction

Introduction | Intraoperative Three-Dimensional Imaging: Technical Description | Limitations | Conclusion | References

Accurate anatomic reconstruction is essential to the achievement of optimal results in trauma surgery, especially in the treatment of complex fractures of the hip and knee joints^1-3. Computed tomography has already been established as a standard imaging modality for fracture analysis and classification and for dedicated treatment planning^4-7. In addition, computed tomography has been proven to provide the surgeon with valuable information, including fracture orientation in three dimensions^4,8-10.

In recent years, postoperative computed tomography has been used for analysis of the results of reconstruction and implant placement, for follow-up in fracture-healing, and in selected cases of revision surgery^4,11-14.

However, for intraoperative decision-making, the surgeon still has to rely on visualization of the approach and two-dimensional imaging provided by conventional C-arm technology. Although successful clinical reports on the use of intraoperative computed tomography have been reported, this technology is used in a limited number of hospitals and has been described primarily for neurosurgical applications. Major limitations of intraoperative computed tomography include not only the high costs and necessary maintenance, but also the need for designated radiographic technicians. In addition, there may be practical problems due to the considerable weight of the intraoperative computed tomographic scanner^15,16. Furthermore, especially in orthopaedic trauma applications, the computed tomographic scanner limits the space that may be necessary for reduction maneuvers, and sterility remains a problem. Consequently, no routine clinical use in orthopaedic or trauma surgery has yet been established, to our knowledge.

In evaluating the actual information that would be expected to be gained from use of an imaging device, an orthopaedic trauma surgeon would typically ask the following questions: What is the quality of reduction? Are there any residual steps or gaps? Are the implants positioned correctly? Could any intra-articular implant lead to progressive and/or rapid joint destruction?

A clinically relevant example that illustrates these problems is percutaneous sacroiliac screw fixation, a minimally invasive procedure that is performed frequently. Preoperative computed tomography provides the surgeon with excellent information regarding the three-dimensional anatomy (Fig. 1). The technique is standardized and has been described in detail¹⁷. However, the operation has its own pitfalls, such as nerve root injury or insufficient fixation, with the reported prevalence of surgical technique-related failures ranging from 3% to 17%¹⁸. These failures are mainly related to the limited two-dimensional intraoperative visualization that is provided by a conventional C-arm, compounded by the presence of bowel gases, osteoporosis, and obesity (Fig. 2).

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Fig. 1: A preoperative computed tomographic scan of the pelvis provides the surgeon with excellent information regarding the three-dimensional anatomy of the sacral fracture.

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Fig. 2: Two-dimensional intraoperative visualization of the pelvis can be limited due to bowel gas, osteoporosis, and obesity.

Similar to the way in which intraoperative three-dimensional imaging may help in the control and evaluation of a distinct screw position, computer navigation is able to provide a three-dimensional image of the sacrum and the surgical tools (i.e., the drill-bit) during the actual drilling procedure¹⁹. Although some surgeons prefer the computer-navigated technique because they believe it provides for a safer procedure, to our knowledge, no prospective clinical randomized trial has yet proven that navigation is the superior technique^20,21.

In a controlled clinical case series in which computed tomography was used in this manner, we proved that a novice in pelvic surgery could place sacroiliac screws with the aid of navigation just as safely as a more experienced pelvic surgeon could perform the same procedure with use of the conventional technique; however, the navigated procedure was associated with an operative time that was doubled (average, ninety minutes) when compared with the operative time of the conventional procedure (unpublished data).

This article provides an overview of the actual utility of intraoperative three-dimensional imaging at the hip and knee joints with and without the additional use of navigation. In addition to the possible clinical applications, the pitfalls and limitations are also discussed.

Intraoperative Three-Dimensional Imaging: Technical Description

Introduction | Intraoperative Three-Dimensional Imaging: Technical Description | Limitations | Conclusion | References

Intraoperative three-dimensional C-arms were introduced clinically in 2001²². The three-dimensional C-arms (SIREMOBIL Iso-C^3D; Siemens Medical Solutions, Erlangen, Germany) consist of a standard mobile C-arm system, a motorized orbital motor, and hardware and software components for three-dimensional imaging. The technique for isocentric intraoperative three-dimensional scanning begins with a complete secondary sterile draping of the entire region of interest. Because the Iso-C^3D rotates between 130° and 190° around the operative field, it is difficult to ensure that nonsterile components of the initial surgical drapes are not caught on the C-arm and inadvertently shifted into the sterile field. To guard against this possibility, a second sterile drape can be used to cover the field; this drape is then discarded after imaging has been accomplished.

The three-dimensional C-arm must be positioned so that the region of interest is isocentric on both the anteroposterior and lateral projections. This may be confirmed with orthogonal images. Three-dimensional imaging is then performed by calculating multiplanar reconstructions from fifty to 100 C-arm images that are registered during one automated rotating scanning procedure, generating a high-resolution isotropic data set consisting of cubes of approximately 12 mm³. From this data set, axial scans are first generated, followed by reconstruction into coronal and sagittal slice orientations. On the basis of the possible dynamic visualization and active scrolling of the images, the surgeon can utilize all generated multiplanar reconstructions and thus make informed decisions on optimal fracture reductions and residual fracture gaps as well as proper implant placement.

During the automated scanning procedure, the rotating C-arm should not be allowed to collide with anything or anyone, as this will cause an immediate scan stop and failure. Therefore, prior to the scan, a collision check for the complete rotation should be performed. After scanning, the data set may also be transferred to a navigation system (e.g., VectorVision; BrainLAB, Feldkirchen, Germany). The navigation system allows for visualization of specific navigated surgical tools in all three planes (coronal, sagittal, and axial).

The benefits of intraoperative reduction assessment and control of implant positioning have been proven by numerous studies for various indications^23-34. Larger retrospective clinical studies have found that, on the basis of the three-dimensional information, the intraoperative revision rates range from 7%³⁴ to 19%³⁵. In foot and ankle applications, revision rates of up to 30% have been described³.

While several studies have reported the successful clinical application of intraoperative three-dimensional imaging with and without navigation, most of these applications were for orthopaedic surgical treatment of trauma injuries of the lower limb and foot as well as for spinal surgery^{23,24,27-29,31,32,34,36-38}. Use in elective hip and knee surgery has been very limited to date, as described in the following sections.

Hip Joint

In an experimental study with fresh-frozen cadavers in which a transverse fracture of the acetabulum had been made, blinded surgeons analyzed the operative results (residual step and implant position) on the basis of (1) use of a conventional two-dimensional C-arm, (2) use of three-dimensional multiplanar reconstructions from an isocentric intraoperative three-dimensional C-arm (SIREMOBIL Iso-C^3D), and (3) use of a thirty-two-slice computed tomographic scanner (General Electric LightSpeed VCT; General Electric Healthcare, Munich, Germany). The results revealed that only eighteen of twenty-four screws were identified correctly with use of a conventional C-arm, twenty-three of twenty-four screws were identified correctly with use of the Iso-C^3D, and twenty-four of twenty-four screws were identified correctly with computed tomography²³.

Clinical applications of intraoperative three-dimensional imaging of the hip joint have been limited to date; however, these applications include intraoperative control after osteosynthesis of acetabular (Fig. 3) or femoral head fractures (Fig. 4). Although intraoperative three-dimensional imaging at the hip joint necessitates extensive and complex patient positioning and draping, the visualization of unintended intra-articular screw placement or reduction failure may avoid additional postoperative computed tomographic scanning and, more importantly, revision surgery.

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Fig. 3: Intraoperative three-dimensional imaging control (left) after osteosynthesis of an acetabular fracture, compared with a postoperative computed tomographic scan (right).

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Fig. 4: Intraoperative three-dimensional imaging control after osteosynthesis of a femoral head fracture.

Two-dimensional navigation at the hip joint has been described for the placement of screws in the femoral neck or across subtrochanteric fractures; however, the combined use of three-dimensional imaging and navigation has been applied infrequently at the hip joint. Related sacroiliac screw three-dimensional C-arm navigation has been in successful clinical use since 2003^21,39. Screw placement in the acetabular column under three-dimensional navigated control and secondary intraoperative control with use of another three-dimensional scan has also been described. However, due to the overall limited prevalence of this specific injury, very few medical centers have applied this technique to date.

Another limited indication is retrograde drilling of osteochondral or small tumor lesions during minimally invasive three-dimensional navigated techniques.

Knee Joint

One of the most promising areas for intraoperative three-dimensional imaging at the knee joint is the enhancement of minimally invasive procedures. During arthroscopic reduction and fixation of tibial plateau fractures, intraoperative three-dimensional imaging provides precise information about the result, avoids standard approaches (Fig. 5), and has been successful in clinical use²⁴. Wound complications and nerve injuries have frequently been associated with open reduction and internal fixation of tibial plateau fractures and thus minimally invasive approaches have a high potential to reduce morbidity⁴⁰. The complex three-dimensional anatomy of the distal part of the femur where it articulates with the tibial plateau often necessitates multiplanar imaging in order to confirm correct intra-articular hardware placement. However, prospective studies that make use of intraoperative three-dimensional imaging during this procedure are still needed.

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Fig. 5: Arthroscopic reduction (left) and fixation of a tibial plateau fracture with combined intraoperative three-dimensional imaging (center) and postoperative two-dimensional control (right).

When three-dimensional imaging is used in combination with navigation, it becomes possible to match preoperative magnetic resonance imaging and intraoperative three-dimensional scans for precise targeting, for example, in the drilling of osteochondral lesions about the knee joint as part of a minimally invasive technique (Fig. 6)⁴¹. A more recently described application is real-time navigated control during reduction and fixation of fractures of the tibial plateau. With the help of a navigated pointer, the surgeon is able to control the reduction while comparing the anatomy of the injured knee to a three-dimensional preoperative data set of the contralateral uninjured knee. A comparable technique has already been performed successfully in various craniomaxillary operations^42,43.

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Fig. 6: Intraoperative fusion of preoperative magnetic resonance images and intraoperative three-dimensional images (left) during navigated controlled drilling of an osteochondral lesion of the knee (right).

Limitations

Introduction | Intraoperative Three-Dimensional Imaging: Technical Description | Limitations | Conclusion | References

A major criticism of new techniques such as navigation with three-dimensional imaging is the additional intraoperative time required. In a study conducted by us from 2003 to 2005, the time required for intraoperative three-dimensional imaging of 248 patients was analyzed³⁶. In accordance with the learning curve, the setup and scanning time was shown to improve from an initial sixteen minutes in 2003 to seven minutes in 2005. Of note, the time taken for intraoperative analysis of the images by the surgeon changed from five minutes in 2003 to an average of seven minutes in 2005. As a consequence of the three-dimensional intraoperative imaging, intraoperative revisions were performed in forty-seven (19%) of 248 patients, with an improvement in fracture reduction in twenty patients (8%) and in implant positioning in twenty-seven patients (11%)³⁶.

At present, intraoperative three-dimensional imaging is performed with use of three-dimensional C-arms. Thus, the image quality is limited compared with regular computed tomographic scanners (Fig. 7). However, the surgeon is able to judge his or her operative result during the procedure and revision surgery may be avoided. Therefore, despite the costs associated with the use of a three-dimensional C-arm, there are financial benefits^35,44. Initial costs include purchase of the three-dimensional C-arm and maintenance, which, on the average, is $3200 per year. However, as costly revisions may be avoided, a theoretical financial benefit is achieved when 240 patients per year undergo an intraoperative three-dimensional scan³⁵.

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Fig. 7: Comparison of image quality between three-dimensional intraoperative images (left) and regular postoperative computed tomographs (right) after open reduction and internal fixation of a tibial plateau fracture in various planes.

Additional limitations include the specific positioning techniques and equipment needed, especially for procedures at the hip joint. Metallic positioning tables, clamps, or positioning arms can cause artifacts on the three-dimensional intraoperative scan. Therefore, radiolucent tables or extremity attachments are recommended. With regard to tables with a large diameter and in the case of obese patients, three-dimensional imaging may be incomplete due to an inability to complete a full rotation arc.

Navigation with the incorporation of intraoperative three-dimensional imaging technology has been viewed as a logical step to harness the benefits of these new technologies. However, prospective clinical studies to definitely establish the benefits of this technology are currently lacking. It is clear, however, that at present, these navigated procedures are time and cost intensive.

Major limitations of navigated applications at the hip and knee joint are related to the need for invasive reference markers for registration. The reference markers have to be rigidly fixed to the region of interest. This is usually achieved with single or double Schanz screw-like fixation systems. Any loosening of the reference marker can cause relevant inaccuracies^45,46. Noninvasively fixed reference markers can only be used in joints in which any further movement of the region of interest is avoided, which is unlikely for most interventional applications.

Conclusion

Introduction | Intraoperative Three-Dimensional Imaging: Technical Description | Limitations | Conclusion | References

Intraoperative three-dimensional imaging is a recent development and has been adopted in some centers, primarily in Germany, for applications in orthopaedic trauma surgery. It is evident that there is a paucity of studies in the orthopaedic literature, as only a few retrospective uncontrolled studies have been reported⁴⁷. However, the benefits of intraoperative three-dimensional imaging for the surgeon are apparent. Computed tomography-like images can provide valuable information on the operative result intraoperatively in both the hip and knee. "Good" surgical results can be improved and problems can be detected and fixed immediately. Financial benefits, which are crucial in any health-care system, are apparent if and when revision surgeries are avoided due to the ability to assess results intraoperatively.

The use of computer-aided navigation during orthopaedic surgery for the treatment of trauma to the hip or knee joint has been limited to drilling applications (e.g., for osteochondral lesions, tumor biopsies, and the placement of certain screws, such as those placed in the anterior or posterior column during acetabular osteosynthesis)^20,21,39. An important step forward would be the use of computer-aided navigation during fracture reduction, which has already been shown to be feasible⁴⁸; however, because it is time-consuming, its use should be restricted to experienced navigation centers.

For intraoperative three-dimensional imaging, a recently introduced fully digital flat-screen detector (Ziehm Vision FD Vario 3Dl; Ziehm Imaging, Nuremberg, Germany) is able to provide high-resolution images that can be imported into the navigation system without distortion (Fig. 8). Furthermore, one might expect robotic-controlled C-arms with full six degrees of freedom to improve the speed of imaging, patient safety, and the ergonomic situation for the surgeon (Fig. 9). Image Not Available

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Fig. 8: A recently introduced three-dimensional C-arm with digital flat-screen detector (left) as compared with conventional three-dimensional C-arm technology (right).

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Fig. 9: Robotic-controlled C-arms with full six degrees of freedom might improve the speed of intraoperative and interventional imaging. (Reproduced with permission of Siemens Healthcare Sector, Erlangen, Germany.)

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Topics

hip joint ; imaging, three-dimensional ; knee joint

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Tobias Hüfner, Timo Stübig, Musa Citak, Thomas Gösling, Christian Krettek, Daniel Kendoff; Utility of Intraoperative Three-Dimensional Imaging at the Hip and Knee Joints with and without Navigation. The Journal of Bone & Joint Surgery. 2009 Feb;91(Supplement_1):33-42.

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