TY - JOUR
T1 - Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures
T2 - introduction of the ‘C-Arm Rotational View (CARV)’
AU - Bleeker, Nils Jan
AU - Doornberg, Job N.
AU - ten Duis, Kaj
AU - El Moumni, Mostafa
AU - Reininga, Inge H.F.
AU - Jaarsma, Ruurd L.
AU - IJpma, Frank F.A.
AU - on behalf of the Traumaplatform 3D Consortium
AU - Goedhart, L. M.
AU - de Cort, B.
AU - Hendrickx, L. A.M.
AU - ter Horst, M.
AU - Gorter, J.
AU - van Luit, R. J.
AU - Nieboer, P.
AU - Füssenich, W.
AU - Zwerver, T.
AU - Koster, R.
AU - Valk, J. J.
AU - Reinke, L.
AU - Bleeker, J. G.
AU - Cain, M.
AU - Beeres, F. J. P.
AU - Kerkhoffs, G. M. M. J.
PY - 2023/12
Y1 - 2023/12
N2 - Purpose: Rotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined ‘C-Arm Rotational View (CARV)’, to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.Methods: A cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort. Results: In total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p = <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.Conclusion: This study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.
AB - Purpose: Rotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined ‘C-Arm Rotational View (CARV)’, to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.Methods: A cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort. Results: In total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p = <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.Conclusion: This study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.
KW - Intramedullary-nailing
KW - Rotational malalignment
KW - Tibia shaft fractures
KW - ‘C-Arm Rotational View (CARV)’
UR - http://www.scopus.com/inward/record.url?scp=85135305660&partnerID=8YFLogxK
U2 - 10.1007/s00068-022-02038-2
DO - 10.1007/s00068-022-02038-2
M3 - Article
AN - SCOPUS:85135305660
SN - 1863-9933
VL - 49
SP - 2329
EP - 2336
JO - European Journal of Trauma and Emergency Surgery
JF - European Journal of Trauma and Emergency Surgery
IS - 6
ER -