Computer Assisted Orthopaedic Surgery

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Computer Assisted Orthopaedic Surgery

• Whats New (and available) for Orthopaedic Trauma
  in 2007
• David Kahler, MD
• 20th Annual SEFS 2007, Greensboro

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Advances in Navigation

• CT-based navigation (early 1990s)
• Fluoroscopic (Surgical) Navigation (1999)
• Tracking of individual fragments (2001)
• Fracture reduction software (2003)
• Improved software dedicated femoral nailing
  application (2004-2005)

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C-arm (fluoroscopic) navigation

• Images are obtained in OR
• C-arm, patient, and instruments are tracked by
  camera and computer
• New images easily obtained
• Best CAOS application for trauma (does not rely
  on preop or intraop CT)

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Audience Response QuestionImage guided surgery
(surgical navigation) is a useful tool during
fixation of femoral shaft fractures.1.
Agree2. Disagree3. Undecided
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Barriers to Acceptance

• Cost of systems (Not available at my hospital)
• Additional O.R. time for fixation of trackers and
  intraop planning steps after obtaining images
• Increased equipment and line-of-sight issues
• Inertia

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Developing Solutions to the Challenges
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Conquering Inertia through Education

• AO MIO/CAS courses, Davos 05 and 06
• AAOS ICL and OTA Symposia 04-06
• BrainLAB Masters course, Las Vegas, February 2007
• AO Faculty Development Course, West Chester,
  March 2007
• AO MIO Course (first US AO course) late 2007
• AO CAS course, Davos 2007

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Basic advantages of navigation for intramedullary
nailing

• Stored images in two planes
• Improved
• Less total fluoroscopy time
• Stops irradiation of surgeon
• Allows the surgeon to exactly match the anatomy
  of the injured side to the other side

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Case Report

• A 29 year old male with multiple lower extremity
  diaphyseal injuries and an acetabular fracture
  following ejection from a motor vehicle
• Bilateral femoral shaft fractures
• Right tibial/fibular shaft fractures
• Left anterior column acetabular fracture

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OR night of injury

• Patient initially stable, lactic acid 1.8
• Plan to stabilize diaphyses and temporize
  acetabular fracture
• Right leg stabilized with retrograde IM femoral
  nail and antegrade tibial nail
• Patient became hypothermic and hypotensive, right
  femur externally fixed and procedure terminated.

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Post-op

• Pelvic angiography negative, but profunda femoris
  artery found to be disrupted on left, embolized

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New problem malrotation

• Patients right lower extremity noted to be
  severely externally rotated, and left leg
  internally rotated
• Is right tibia or femur malrotated?
• Is left femur externally fixed in internal
  rotation?
• Are all three bones malrotated?

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Which is the healthy side?
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Right Femur

• Appeared to be well-reduced

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Tibia

• Spiral fracture malrotated?

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Left femur

• Difficult to determine rotation due to transverse
  pattern with butterfly fragment

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Options for Definitive Management?
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Plan

• Decision made to match anteversion of both femora
  during left femoral IM nailing, and then correct
  tibia if necessary
• Right femoral anteversion measured at six degrees
  intraoperatively using C-arm images
• Navigation used for left femoral nail for
  starting point and reduction, including
  correction of rotation

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Results

• Femur had been externally fixed in 27 degrees of
  antetorsion
• Corrected to 6 degrees at time of nail insertion
• Tibia remained externally rotated, and was
  corrected by rotational reduction and revision of
  distal locking screw

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Result

• Both legs healed in anatomic alignment
• In this case navigation proved useful in both
  diagnosing and correcting a problem with
  malrotation following fracture fixation
• How many femora do we leave malrotated at the
  time of surgery?
• 30 have more than 15 degrees malrotation by CT
• Internal rotation causes measurable gait
  disturbances with as little as 10 degrees

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Future Aspects

• Matching of well leg now available (restoration
  of normal length and rotation)
• Navigated reduction devices
• Visualization of implants

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Integration of MIPO

• Current software allows rudimentary use of
  navigation tools (pointer, drill guide) during
  subcutaneous plating applications
• New application specific software will allow
  surgeon to accurately place specific implants
  using minimally invasive technique (distal
  femoral LCP)

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Room For Growth

• New Hardware integrations
• Hardware specific techniques.
• LCP/DCP integration
• Nail integration

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Navigation in 2007

• New products and software workflows
• Educational programs
• Should be a banner year for adoption of
  navigation as a routine tool in fracture care