Intraoperative Assessment of Fracture Reduction and Implant placement by 3D Floroscopy and Intraoperative Revsion Rate

Background: Intraarticular and pelvic fractures have complex 3 dimensional anatomy. Therefore, intraoperative assessment of fracture reduction, implant placement may be underestimated when using conventional, bi planar fluoroscopy. In certain cases, revision surgery is mandated after postoperative CT scans showing either malreductions or inappropriate hardware placement. In recent years, 3 dimensional fluoroscopes (3DF) have evolved and are being used in few centers in order to overcome these difficulties. The aim of this study was to investigate the intraoperative utilization of the 3DF and its impact on intraoperative decision making.

Methods: Setting: Retrospective cohort analysis in an academic level I trauma center. Between 2017 and 2018, 31 patients underwent intraoperative 3DF (Artis Zeego, Siemens, Germany) for fracture fixation of the spine, pelvic ring, acetabulum and lower extremity (tibial plateau, pilon and calcaneus). Additional cases included lower extremity post traumatic deformity correction. Cases were evaluated according to the type of injury and procedure, the amount of intraoperative imaging, the rate of intraoperative revision of fixation and the need for further postoperative imaging.

Results: 18 patients (58%) underwent a single 3D imaging sequence, only one case (3%) required intraoperative revision; 11 (35%) underwent 2 imaging sequences out of them 3 (9.6%) patients of which required intraoperative revision. Two patients underwent 3 sequences none of which required revision. Overall revision rate of 12.6 %
Of the 18 patients that underwent one sequence, 8(44%) required further early follow up postoperative imaging, of the patients that underwent 2 sequences 8 out of 11 (72%) required further early follow up imaging, and one ( 50% ) of the 2 patients that underwent 3 sequences required further imagining.

Conclusion: Intraopertative 3DF have a major impact on decision making during complex fracture fixation, allowing intraoperative revision otherwise not possible with 2D fluoroscopy. Further investigation is required to asses the clinical significance of these findings