SAN FRANCISCO, Calif. (Ivanhoe Newswire) - A broken pelvis is a painful injury and often a difficult one to repair. Many organs, nerves and blood vessels lie within the pelvis, so getting to the bones can be tricky. Now, surgeons are using new technology to go to fix the problem.
Jenna Quarne goes up and down every day, but she'll never forget the terrifying bike ride she recently took.
"The car in front of me was taking a right, so I just moved over to kind of go around them," Jenna Quarne told Ivanhoe.
Jenna's bike got caught in railway tracks and the momentum of the downward hill kicked in.
"It just threw me off the bike, and I landed in the street," Jenna said. "I knew that something probably severe was wrong."
Jenna shattered her pelvis and needed surgery to repair it. Doctor Amir Matityahu used computer-guided navigation to fix Jenna's fracture.
"The whole idea of navigation is pretty simple. It's creating a virtual space for you to work in so you don't have to use radiation," Amir Matityahu, M.D., an orthopedic surgeon at UCSF, explained.
Instead of having to take numerous X-rays during the surgery, the doctor uses the computer software to plan the procedure. First, sensors are placed on the pelvis. Then the system turns cat scans into a 3D model. The computer creates a roadmap, much like a GPS, that tells the surgeons precisely where to place the bone-repairing screws.
"The trajectory has to be almost exact," Dr. Matityahu said. "It has to be between 1-2 degrees and 1-2 millimeters."
A green marker shows he's marking the correct spot right inside the bone. If he places it in the wrong spot, a red alert lets him know.
"So, red is bad. Green is go," Dr. Matityahu said.
The navigation method means better accuracy, possible quicker surgery, and fewer pieces of hardware. Also, since surgeons don't have to keep taking X-Rays, there's less radiation exposure.
It's been four months since Jenna's surgery. Now, she's back to walking the hills of the city she loves.
"No pain, I can't tell at all," Jenna said.
The doctor said he's one of only about five surgeons in the country using this software for this type of surgery. He said the software was just recently FDA approved for this procedure and a few other orthopedic applications.
BACKGROUND: The pelvis consists of three major bones joined together in a ringed shape and held by strong ligaments. General characteristics of pelvic fracture include severe pain, pelvic bone instability, and associated internal bleeding. Pelvic fractures occur rarely. They are commonly associated with high-energy traumatic events such as falls or automobile or motorcycle accidents. A variety of pelvic fracture injuries may occur. Zones of typical injury include: symphysis pubis dislocation; pubic ramus fracture; iliac fracture; sacroiliac joint dislocation and sacral fracture. (www.orthop.washington.edu)
COMPUTER-ASSISTED NAVIGATION: Computer-assisted navigation offers several potential
benefits in the surgical management of patients. Preoperatively, this technology offers improved visualization of the operative field and facilitates surgical planning. Intraoperatively, data from real-time imaging can be merged with MRI and CT scans to create a virtual map of the operative field. Initially used in applications related to total joint reconstructive surgery, spine surgery, and orthopedic trauma computer-assisted navigation improves accuracy and has superior precision, particularly with regard to implant positioning and function. Doctors have been able to minimize leg length discrepancies, improve restoration of the joint line, and address rotational concerns of implant alignment. A current limitation of computer-assisted navigation is the need for increased surgical time. Critics and even early proponents of the technology noted that adding more time to already lengthy surgeries increases the risk of infection and adverse events. Cost has also been noted as a negative consequence of the technology. (www.moffitt.org/CCJRoot/v18n3/pdf/171.pdf)
DR. AMIR MATITYAHU: In 2003, Dr. Amir Matityahu joined the staff at UCSF/SFGH. He is presently the Director of Pelvis and Acetabular Trauma Reconstruction at San Francisco General Hospital and is an Assistant Clinical Professor in the Department of Orthopaedics at the University of California, San Francisco, (UCSF). His clinical areas of interest are high-energy complex periarticular fractures, pelvis and acetabular fractures, and the polytraumatic patient with orthopaedic injuries. His research interests include the bio mechanics of fracture fixation and the post-traumatic hip joint. In addition, Dr. Matityahu is constantly developing innovative and minimally invasive surgical techniques. Dr. Matityahu's goal is to provide the highest quality of medical care available to all of his patients, promote, encourage, foster, and advance the art and science of orthopedic surgery. Matityahu was born in Israel and moved to Palo Alto, CA in 1978. He received his bachelor of science degree in Kinesiology from UCLA in 1992 and graduated from the Hahnemann University Medical School in Philadelphia in 1997. He received his orthopaedic residency training from Maimonides Medical Center in Brooklyn, NY. In 2002, he further trained in Orthopaedic Traumatology through a fellowship at the Adams R. Cowley Shock Trauma Center, a world-renowned trauma center.
Dr. Amir Matityahu. Director of Pelvic and Acetabular Trauma and Reconstruction, University of California, San Francisco, talks about repairing hip fractures with a combination of surgery and computer assisted surgery.
Tell me about what you did with Gina, she was really kind of a rare case wasn't she?
Dr. Matityahu: When we saw Gina she presented with a both column acetabular fracture. The hip joint is made of a ball and a socket. The socket portion is called the acetabulum. The Acetabulum is a word from ancient Greek that means little vinegar cup. The little cup is this area right here and what you're seeing is a three-dimensional rendering of her problem from a CT scan.. The whole idea is that the cup, which is this portion, gets hit by the ball so the ball impacts the cup and it kind of blows up like this. When the acetabulum is fractured you have to fix it somehow. Otherwise, the patient will develop early arthritis in the hip joint. Subsequently, it's very hard to walk and to do everything you want to do every day.
Her hip was basically shattered?
Dr. Matityahu: Her hip was shattered but it's not like an elderly person's hip fracture. An elderly person's hip fracture occurs on the femur side, that is, on the ball side of the hip joint. Her hip was shattered on the socket side, which usually happens to young people with good bone. The number of patients that we see with this every year is somewhere around thirty to fifty in this institution. Most of them are not this bad and are easier to treat than this one. What happened to her, Lets look at the CT scan without the ball and with just the socket. The hip socket is supposed to be very smooth and round. What you see here is a gapped and fractured socket. Because there are gaps, the ball can't articulate with the socket very smoothly and it gets arthritis really quickly. What you're seeing is that, that gap occurred because the ball right here was pushed in to the acetabulum causing it to explode inward.
So basically a decade ago she would have a hard time walking for the rest of her life and have arthritis for sure?
Dr. Matityahu: Not just a decade ago in some places in this country people are having problems fixing these problems and really it takes many cases to get good at it. So it's one of those procedures that if you do a lot you know what you're doing if you don't do them a lot you're a novice and you don't do them well. There are studies looking at one person versus a bunch of people fixing these kinds of fractures. When the one person fixes the acetabulum, they do it better than a bunch of people doing it. The outcomes seem to be better.
So that's her problem. In her case, we used technology help manage the fracture fixation. We used a combination of an open procedure and percutaneous procedure to fix the broken acetabulum. Normally, the large open procedure is standard. However, what we did in her case was use navigation, which is computer-assisted surgery, to take care of her acetabular fracture. And that's something that a very few people are doing in this country right now.
You talk about all these technical things is there more pressure on you know she's just been here for three days and she's has a wedding coming up?
Dr. Matityahu: Well there's always pressure when there's a young person who has the rest of their life ahead of her. If we don't bring them back to their normal activities of daily living, they may suffer the rest of their life with hip pain, difficulty walking or even exercising.
Dr. Matityahu: What you're seeing here is our preoperative plan. We perform a CT scan and turn it into a three-dimensional model of the pelvis and acetabulum. We then look at the broken side versus the non-broken side to help us think about how to put the bones back where they need to be and where the hardware should be placed. What you're seeing here are tubes that represent where the screws will be placed during the surgery. Here is her x-ray, which is a two-dimensional image representing a 3 dimensional problem. Ten to fifteen years ago we had to look at these x-rays, or two-dimensional images, to find out exactly what was happening with the acetabulum. This is another two-dimensional image again seeing the same thing. Today, inter-operatively we're able to take that two-dimensional image and rotate it to create a three-dimensional image with much better in visualization.
What were the mistakes that could happen here?
Dr. Matityahu: The biggest mistake the surgeon can make is choose the wrong surgical approach to fix the fracture. Meaning how do I get to the bone to fix it. And if you make a mistake in which direction you approach the fracture, you can't really put the bones in the right position for them to heal properly. So that's the major issue.
What does that mean for the patient?
Dr. Matityahu: That means another surgery or making another big incision. Keep in mind that these are not small surgeries, these are big surgeries. There are big incisions, big scars and you're going through a lot of tissue to get to the bone. The pelvis holds lots of important stuff within it. So we have to go through or around all that stuff to fix the hip joint from the inside, For instance, we have to move the bladder out of the way in order to get to the medial aspect of the acetabulum. So, the reason we do a combination surgery is that we still have to put the bones back together but instead of making the surgery bigger we're able to put screws percutaneously or navigate with the computer assisted surgery minimizing the amount of trauma we cause the patient. Because the patient had trauma and we're going to cause more trauma by doing the surgery, we try to minimize our portion of the trauma by using technology. The other thing this does for us is that it allows us to use less intra-operative x-rays and minimizing the amount of radiation to the patient and operating team. This point is important because the doctor and operative team are in performing lost of cases every year using fluoroscopy and x-ray. So, if we can minimize the amount of exposure, it is good for the whole team and patient. The other thing that navigation does for the surgeon is accuracy in the placement of implants. I'm able to insert screws in locations that are just a little bit bigger than the screw itself percutaneously. These are corridors that we're going through in the bone. The corridors are eight an ten millimeters in diameter and the screws are six and a half millimeters in diameters. So you have about one degree accuracy you have to deal with in order to be inside the bone. If you go outside the bone you can hurt structures that are around the bone.
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