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. 2023 Sep 25;15(12):3317–3325. doi: 10.1111/os.13874

A New Technology Using Mixed Reality Surgical Navigation with the Unlocking Closed Reduction Technique Frame to Assist Pelvic Fracture Reduction and Fixation: Technical Note

Jiaqi Li 1,2, Lin Qi 1,2, Ning Liu 2, Chengla Yi 3, Haoyang Liu 4, Hua Chen 1,2,✉, Peifu Tang 1,2,✉
PMCID: PMC10693998  PMID: 37749773

Abstract

Background

Pelvic ring disruption (PRD) is a serious trauma associated with high mortality and disability rates. Poor reduction can lead to complications such as pelvic deformity and delayed fracture healing. Here, we introduce a new technology using mixed reality surgical navigation (MRSN) with an unlocking closed reduction technique (UCRT) frame to assist pelvic fracture reduction and fixation.

Methods

Thirty patients with PRD were enrolled in this study. All of the patients underwent preoperative CT scans, with the pelvis and tracker segmented into three‐dimensional models. Under MRSN guidance, auxiliary reduction screws were inserted to grasp the pelvic bone. An ideal trajectory for closed reduction was planned, and suitable CS screws were used for stable fixation after good reduction. Operation time, fluoroscopy frequency, and both Matta and Majeed scores were analyzed.

Results

The mean follow‐up period was 10.8 months (7.5, 12.25 months) (range 6–24 months). The average duration of operation was 212.5 min (187.5, 272.8 min) (range 133–562 min), and the average reduction time was 23.0 min (15.0, 42.5 min) (range 10–70). The average fluoroscopy frequency was 34.0 times (31.5, 52.5 times) (range 23–68 times). One hundred and fifty screws were successfully inserted on the first attempt. All the fractures healed well with no complications. Excellent reduction quality (Matta score ≤4 mm) was achieved in 29/30 cases, and good reduction quality (Matta score between 4 and 10 mm) was achieved in 1/30 cases. All patients achieved bone healing after an average of 4.0 months (3.5, 5.9 months) (range 3–6), as well as good function recovery with an average Majeed score of 91.0 (87.8, 95.0) (range 71–100).

Conclusion

The MRSN technique described improved reduction accuracy and radiation exposure without considerable extension of operation time.

Keywords: Computer‐Assisted Surgery, Pelvic Fracture, Surgical Navigation, UCRT Frame‐Based Closed Reduction, Voxel Registration

Closed reduction and fixation of displaced pelvic fracture are achieved with a new technology using mixed reality surgical navigation with an unlocking closed reduction technique frame that utilizes a high precision voxel registration method based on a preoperative CT three‐dimensional image to finish the registration of a virtual pelvis and a real pelvis.

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Introduction

Pelvic ring disruption (PRD) is a serious pelvic trauma with high mortality rates, ranging from 4.1% to 9.1%, 1 and disability rates ranging from 23.0% to 37.5%. 2 The incidence of postoperative complications has reached as high as 25%, and most of these complications are associated with operative exposure. 3 , 4

Currently, closed reduction with corridor screw (CS) fixation that achieves an excellent or good reduction of 85% is considered a good alternative to open surgery. This strategy also has advantages such as reduced bleeding volume and a lower infection rate. 5 , 6 , 7 However, this technique can involve excessive exposure to radiation for both surgeons and patients due to frequent use of intraoperative fluoroscopy (>150 times on average) during the procedure. 8 , 9 , 10 For example, Gras et al. reported that placement of an iliosacral joint screw or pubic ramus screw requires 123 ± 12 s of fluoroscopy. 9 In addition, Routt et al. reported that the average fluoroscopy duration per operation is 3:48 min for closed reduction and fixation of pelvic fractures. 10 Several computer‐assisted navigation systems have been developed to improve the safety and accuracy of CS placement while also reducing radiation exposure. 11 , 12 , 13 , 14 , 15 However, few reports have described the use of surgical navigation to assist fracture reduction.

Accurate reduction is a prerequisite for optimal screw placement. However, due to the complexity of the pelvic anatomical structure, the closed reduction process cannot be directly monitored. Consequently, the success of a closed reduction procedure relies on a certain degree of luck. Several reduction tools and techniques, including the Matta, 16 Starr, 17 , 18 , 19 and unlocking closed reduction technique (UCRT) 20 frames, have been developed to allow surgical navigation‐assisted closed reduction to be performed. 21 , 22 More recently, a new technology using mixed reality surgical navigation (MRSN) with the UCRT frame has been developed that allows real‐time monitoring of fracture fragment displacement to instruct pelvic fracture reduction. This new technology can also help determine the CS trajectory for fixation of the pelvic ring after good reduction. This paper aimed to evaluate (i) the accuracy, (ii) radiation exposure, and (iii) feasibility of MRSN with the UCRT frame for pelvic closed reduction and fixation.

Patients and Methods

Patients with PRD who visited our hospital between September 2018 and December 2022 were recruited for this study. The inclusion criteria were as follows: (i) definite pelvic ring disruption; (ii) aged 14 to 80 years with no contraindications for surgery; and (iii) OTA/AO classification B/C. The exclusion criteria were as follows: (i) open pelvic injuries or (ii) pathological fractures, severe medical complications, and other associated severe injuries such as traumatic brain injury. A total of 30 patients with pelvic ring disruption (PRD) were enrolled in this study and subsequently underwent preoperative CT scans.

This study was approved by the Institutional Review Board of PLA General Hospital (No. S2021‐340‐01), and signed informed consent forms were obtained from all of the participating patients. In addition, this study was performed in accordance with the ethical standards of the Declaration of Helsinki from 1964. The work is reported according to STROCSS criteria. 23

Preoperative Preparation

In a CT room, each patient was administered local anesthesia. A special set screw connected to a reference frame with an infrared reflective tracker was firmly secured to the bilateral iliac crest (Fig. 1). Subsequently, the pelvis and bilateral trackers were scanned with a CT machine (layer thickness, 1.0 mm; spacing, 0.8 mm). Digital imaging and communications in medicine data for the CT images collected were transferred to a planning workstation using a universal serial bus flash drive. Both the pelvis and the infrared reflective trackers were segmented manually using Mimics Medical software 19.0 (Materialize, Leuven, Belgium) (Fig. 2). In addition, stereolithography files for each fractured pelvis and associated infrared reflective trackers were transferred to the HoloSight Navigation System (Beijing Noitom, China; authorized patent numbers: CN210727852U, US11534240B2, JP7240519B2, and CN109820590A).

Fig. 1.

Fig. 1

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Design of the reference frame (A), the infrared reflective tracker (B), and the special set screw (C). The special set screws connecting the reference frame with the infrared reflective tracker are firmly secured to the iliac crest of the pelvis in schematic diagrams (D, E) and clinical settings (F).

Fig. 2.

Fig. 2

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Reduction strategy for Tile OTA‐61 C1.2 with surgical navigation. (A) The pelvis was segmented with a tracker with infrared‐reflecting tracker using the MIMICS software. (B) The right pelvic reduction target position (#8) was set by mirroring the left ilium at the perpendicular midline plane of the sacrum. (C) The right mirrored ilium (#8) was translated or rotated to the location of the fractured right ilium (5). (D–F) The reduction strategy was simplified into the translation or rotation of ilium #5 by controlling the long screw, grasping the pelvic bone, and applying supracondylar traction to the distal femur. 1. The green tracker represents the right ilium. 2. The violet tracker represents the left ilium, and the mirrored left ilium is the reduction target position for the right ilium. 3. Left ilium. 4. Sacrum. 5. Right ilium. 6. Right fractured pubic and ischial ramus. 7. Right fractured posterior ilium. 8. Mirrored right ilium from left ilium. 9. Anterior superior ilium spine. 10. Pubic symphysis. 11. Posterior superior ilium spine.

Navigation Calibration and Registration of Pelvic Bone or Surgical Instruments

High‐precision voxel model data, including pelvis and infrared reflecting trackers, were generated based on preoperative CT three‐dimensional (3D) imaging. Under an optical tracking system, the pelvic bone or surgical instrument was calibrated and registered according to the voxel registration method (Fig. 3). An infrared‐reflecting tracker was attached to each reference frame that was fixed onto various objects, including the bilateral ilium, surgical table, fluoroscopy machine, and surgical instruments. Both the position and rotation of each tracker were captured by the optical tracking system used during surgical navigation. Calibration was performed by registering the spatial relationship between the bone/drill sleeve and the reference frame. Subsequently, the movement and spatial position of the bone/drill sleeve were visualized.

Fig. 3.

Fig. 3

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Flow charts of voxel registration method.

Notice

  1. The navigation reference frame with infrared reflective trackers should be firmly installed at the iliac crest. If the position between the infrared reflective trackers and the real pelvis changes, this system will not work throughout the procedure. The screw used to fix the reference frame should be of sufficient length to enter the iliac crest, pass along the gluteal pillar, and exit the lateral ilium cortex. Another anti‐rotation pin should be used to prevent the rotation of the reference frame.

  2. A 1‐cm long incision should be made on the bone surface at the screw entry point in the caudal direction. Skin and fascia should be avoided to prevent interference with the reference frame and displacement of the reference frame.

  3. To ensure accurate registration, the pelvis should be divided into two ilium segments according to the anatomical structure but not according to the fracture line (Fig. 2D). Each reference frame represents the corresponding ilium, although the position of the sacrum cannot be realistically visualized.

Installation of Pelvic Unlocking Closed reduction Technique Frame

After being administered general anesthesia, each patient was placed in a supine position on a radiolucent surgical table. Their chest was fixed to the table with a chest strap. Femoral transcondylar traction was applied using a rigid traction system. A pelvic UCRT frame was connected to the operating table, and a connecting rod was used to stabilize the spatial reduction construct for each pelvic fracture. 20 , 24 , 25

Notice

  1. When installing the connecting rods of a pelvic UCRT frame, whether the connecting rods will prevent the C‐arm from obtaining images of the outlet and inlet views of the pelvis should be considered. The latter images are needed to perform registration during the definitive fixation procedure.

  2. Infrared reflective trackers should be carefully protected to avoid colliding with the pelvic UCRT frame during the procedure. Otherwise, the accuracy of the navigation system may be affected.

Navigation‐Assisted Placement of Auxiliary Long Screws for Reduction

Under guidance provided by the surgical navigation system, two Schanz screws (length 40 cm; diameter 6 mm) are inserted in the supra‐acetabular position (Fig. 4) under the guidance of virtual anteroposterior (AP) and lateral views of the pelvis. An additional two screws are inserted at the LC‐2 trajectory position under the guidance of virtual iliac oblique and iliosacral joint inlet views (Fig. 5).

Fig. 4.

Fig. 4

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Placement of supraacetabular screw. (A) Intraoperative view with the Noitom navigation system. (B) Virtual anterior–posterior view. (C) Anterior–posterior fluoroscopy. (D) Virtual lateral view. 1. Drill sleeve with the tracker. 2. Virtual drill sleeve. 3. Drill sleeve and screw on fluoroscopy.

Fig. 5.

Fig. 5

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Placement of right LC‐2 screw. (A) Intraoperative view with the Noitom navigation system. (B) Virtual iliac oblique view. (C) Iliac oblique fluoroscopy. (D) Virtual iliosacral joint inlet view. (E) Iliosacral joint inlet fluoroscopy. 1. Drill sleeve with the tracker. 2. Virtual drill sleeve. 3. Drill sleeve and screw on fluoroscopy.

Notice

  1. The purchase of Schanz screws should be preliminarily confirmed after each screw is fixed. This is particularly important for fragile pelvic fractures and predicts the strength of unlocking and closed reduction steps in the next procedure.

  2. Supra‐acetabular screws should be fixed with bicortical fixation. Be alert to the risk of potential damage to abdominal organs that can be caused by the insertion of screws to an excessive depth.

Mixed Reality Surgical Navigation‐Assisted Fracture Reduction

The UCRT technique was performed as previously described. 16 , 17 , 18 Briefly, the normal hemipelvis was secured before the displaced injured hemipelvis was aligned and rotated to the target position. The latter was achieved through a pelvic symmetric reduction method based on the structural symmetry of the pelvis (Fig. 2). First, the position of the pelvis was adjusted, and displacement of the pelvic fragments was subsequently observed in multidimensional views under the guidance of MRSN. Second, the right pelvic reduction target position (Fig. 2, #8) was set by mirroring the left ilium at the perpendicular midline plane of the sacrum (Fig. 2B). Third, the right mirrored ilium (Fig. 2, #8) was translated or rotated to the location of the fractured right ilium (Fig. 2, #5) (Fig. 2C). Subsequently, the reduction strategy was simplified with translation or rotation of ilium #5 to the position of #8 by controlling the long screw that grasped the pelvic bone and applying femoral supracondylar traction to the pelvis (Fig. 2D). In brief, the pelvic closed reduction procedure was simplified by reducing the bony landmarks, anterior superior iliac crest (9), pubic tubercle (10), and posterior superior iliac crest (11) (Fig. 2E,F). Physical reduction of the pelvic fragments was projected into a 3D visualization system in real‐time under the MRNS. The surgeon was also able to switch the viewpoint, zoom the field of vision, adjust the display mode of the pelvic fragments at any time, observe the gap/interpenetration of the broken end of the fracture, and ensure the accuracy of the reduction procedure under the mixed reality environment.

Notice

  1. The pelvic reduction strategy is simplified into reduction of the bony landmarks such as the pubic tubercle and the anterior and superior iliac crests.

  2. Attention should be paid to prevent excessive force from being applied during the process of reduction and traction. Excessive force can exceed the purchase of the screws and cause a screw to loosen or displace from the bone, thereby leading to screw failure and iatrogenic fracture.

Mixed Reality Surgical Navigation‐Assisted Definitive Fixation

After achieving satisfactory reduction, confirmed by C‐arm examination, a suitable CS was implanted to fix the fracture (Fig. 6). Posterior fixation was performed using 7.3‐mm partially threaded transiliac‐transsacral screws. Additional stability was provided by inserting an anterior subcutaneous internal fixator. A surgeon can observe and control the placement procedure of the screws in real time under the MRNS by installing the bone/drill sleeves of the optical tracker. This ensures that the navigational screw channel is accurately and safely controlled in cortical bones.

Fig. 6.

Fig. 6

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Typical image change in X‐ray and three‐dimensional computer tomography reconstruction performed before and after reduction in a 44‐year‐old woman with OTA type 61‐C1.2 fracture. The outcome of the reduction was excellent.

Notice

  1. Fluoroscopy must be used for final confirmation after pelvic reduction and screw fixation are completed.

  2. For patients with anterior pelvic ring injuries, external or internal fixation devices are used for pubic ramus fractures. Symphyseal separations are treated with cannulated screw fixation of the symphysis.

Postoperative Management

The time required to insert each screw, as well as fluoroscopy time, were recorded. After surgery, radiographs of the pelvis were obtained to assess the fracture reduction and fixation quality achieved. The patients were encouraged to perform isometric quadriceps exercises on the first postoperative day and crutch‐assisted walking on the second postoperative day. Full weight bearing was allowed based on a radiographic assessment of fracture healing. Pelvic fracture reduction was evaluated using the Matta radiological scoring system. 26 Functional status at the last follow‐up was assessed using the Majeed functional scoring criteria. 27

Matta Radiological Scoring

Matta scoring is one of the most frequently used tools to assess the reduction effect of pelvic fracture displacement. Scoring is performed according to the maximal displacement measured on AP, 40° caudad (inlet), and 40° cephalad (outlet) radiographs as follows: excellent (≤4 mm), good (4–10 mm), fair (10–20 mm), and poor (>20 mm).

Majeed Functional Scoring

Majeed scoring is used to evaluate function after major pelvic injuries. Five factors are assessed and scored: pain, standing, sitting, sexual intercourse, and work performance. An overall score of 100–85 is considered excellent, 70–84 is good, 55–69 is acceptable, and < 54 is poor. This scoring system allows early and late results between various methods of treatment to be compared.

Statistical Analysis

Statistical analysis was conducted using SPSS26.0 software (International Business Machines, Armonk, NY, USA). For data following the normal distribution, the most common descriptive statistics are mean and standard deviation (SD), and for data not following the normal distribution, it is median and (P25, P75).

Results

Patients

Our cohort of patients included 16 males and 14 females with an average age of 43.3 ± 15.7 years (range 15–76 years). According to OTA/AO classification, a type 61‐C1.1 fracture was present in three patients, a type 61‐C1.2 fracture was present in 15 patients, a type 61‐C1.3 fracture was present in seven patients, and a type 61‐C3 fracture was present in five patients. According to the Young‐Burgess classification, 25 cases involved a combined mechanism of injury, three cases involved an AP compression force, and two cases involved a vertical shear force. In addition, 14 of the 30 cases were associated with extrapelvic skeletal injuries. After an average of 8.0 days (7.0, 12.5 days) (range 4–175) after injury, patients were treated with UCRT using MRSN. All patients completed follow‐up by clinical review.

Surgical Information and Pelvic Reduction Quality

Thirty patients were included in this study. The average duration of surgery was 212.5 min (187.5, 272.8 min) (range 133–562), and the average reduction time was 23.0 min (15.0, 42.5 min) (range 10–70 min). The average fluoroscopy frequency was 34.0 times (31.5, 52.5 times) (range 23–68 times), and the average intraoperative blood loss was 30.0 mL (20.0, 62.5 mL) (range 10–1200 mL) (Table 1). One hundred and fifty screws were successfully inserted on the first attempt. Based on the Mata scale assessment, the rate of fracture reduction was 100% (30/30). Specifically, excellent reduction quality (Matta score ≤4 mm) was achieved in 29/30 cases, and good reduction quality (Matta score between 4 and 10 mm) was achieved in 1/30 cases.

Table 1.

Patients’ surgery information

Surgery information Mean ± SD (95% CI) Median (P25, P75) Range
Time from injury to operation (days) 15.8 ± 30.9 8.0 (7.0, 12.5) 4–175
Operative time (min) 235.3 ± 85.3 212.5 (187.5, 272.8) 133–562
Reduction time (min) 30.7 ± 17.9 23.0 (15.0, 42.5) 10–70
Fluoroscopy frequency (times) 40.3 ± 13.0 34.0 (31.5, 52.5) 23–68
Intraoperative blood loss volume (mL) 118.0 ± 240.4 30.0 (20.0, 62.5) 10–1200
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Complications

Postoperative CT scans showed that all the inserted screws were intraosseous. No post‐surgical complications emerged as the direct result of MRSN with UCRT in all patients. All 30 patients completed follow‐up for an average of 10.0 months (7.5, 12.3 months) (range 6–24).

Clinical Improvements

All patients achieved bone healing after an average of 4.0 months (3.5, 5.9 months) (range 3–6), as well as good function recovery with an average Majeed score of 91.0 (87.8, 95.0) (range 71–100) (Table 2).

Table 2.

Patients’ follow‐up outcomes

Follow‐up information Mean ± SD (95% CI) Median (P25, P75) Range
Last follow‐up time (months) 10.8 ± 4.7 10.0 (7.5, 12.3) 6–24
Bone healing time (months) 4.0 ± 0.8 4.0 (3.5, 5.9) 3–6
Majeed functional score at the last follow‐up 90.2 ± 7.0 91.0 (87.8, 95.0) 71–100
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Discussion

In our study, we showed a new technology using MRSN with a UCRT frame that allows real‐time monitoring of fracture fragment displacement to instruct pelvic fracture reduction. Clinically, a total of 30 patients with unstable pelvic ring disruption were successfully reduced with MRSN with the UCRT frame, and all of the inserted screws were intraosseous, which means that all the screws were in a good position. To the best of our knowledge, this report is the first to describe a closed reduction of PRD with surgical navigation in a clinical setting. Based on these preliminary findings using MRSN with a UCRT frame, we anticipate its application will help instruct pelvic fracture reduction and final definitive fixation.

Accurate Reduction of Pelvic ring disruption with Mixed Reality Surgical Navigation

To date, surgical navigation methods have had limited applications in assisting and guiding surgeons during closed reduction of pelvic fracture procedures. This is because most surgeons perform closed reduction of pelvic fractures using on‐table traction or an external fixator. However, these methods may interfere with the reference frame and introduce new reduction errors. Within the past decade, a frame‐based pelvis closed reduction technique 21 , 22 has been developed that facilitates surgical navigation. Accordingly, the pelvis is not held free hand but is held mechanically by long screws connected to a pull/push device on a pelvic frame (e.g., a da Vinci arm). Reduction is performed by controlling several long screws, such as supra‐acetabular screws, LC‐2 screws, and femoral supra‐condylar traction, which are inserted under fluoroscopy. These screws are used to grasp the pelvis and are subsequently pulled or pushed to achieve closed reduction of PRD according to the fracture displacement directions observed with real‐time fluoroscopy imaging. Repeated real‐time fluoroscopy verification is required during closed reduction and internal fixation, 16 , 21 , 28 thereby increasing the risk of radioactive damage to the patient and medical personnel. In this study, with the use of MRSN, Matta scores were excellent in 29 patients and good in one patient, which means the qualities of fracture reduction were rated as excellent in 96.6% of patients. However, in the previous study with the conventional method, the qualities of fracture reduction were rated as excellent in only 65% of patients. 29

Radiation Exposure is Reduced with Use of Mixed Reality Surgical Navigation

The technology introduced in this study, MRSN, is based on preoperative CT scanning and can be directly employed to monitor fracture displacement simultaneously from multiple‐plane views. The latter include outlet, inlet, anterior–posterior, iliosacral inlet, iliosacral outlet, lateral, obturator oblique, and iliac oblique views. Based on these 3D displays, the surgeon can adjust the direction of the reduction force for closed reduction of PRD according to the displacement direction of the fracture. Accordingly, this system can potentially instruct surgeons to reduce pelvic fractures while also reducing radiation exposure to both patients and medical staff during the surgical process. Using the conventional fluoroscopy method, six or seven CS screws are inserted percutaneously with a fluoroscopy frequency of 150 times. 20 However, in the present study using MRSN, the fluoroscopy frequency was only 34.0 times.

Feasibility of Voxel Registration of Mixed Reality Surgical Navigation

In contrast with other registration methods, MRSN, as described in this study, uses the voxel registration method (Fig. 2). 30 , 31 Calibration and registration of the real pelvis and the virtual pelvis were completed through calibration and registration of an infrared reflective tracker that was connected with a reference frame rigidly fixed to the iliac crest through a special set screw. The latter set screw could potentially confirm a reassembly position error of the reference frame of <0.1 mm. Further, this system can simulate fluoroscopy images of the pelvis and perform real‐time monitoring of the pelvis position through multiple views simultaneously. As a result, the pelvic reduction process does not require real‐time monitoring with fluoroscopy. In addition, the placement of auxiliary long screws for reduction and screws for definitive fixation can be achieved under the guidance of virtual images on two orthogonal planes.

Strengths and Limitations

Overall, this single‐center retrospective study demonstrates the capacity for MRSN with a UCRT frame to reduce PRD. This result is attributed to using a specific voxel registration method and UCRT‐assisted closed reduction of PRD. By making it more straightforward for young surgeons to understand and observe the reduction process of severely displaced pelvic fractures, greater awareness and development of minimally invasive pelvic technologies are anticipated. However, the present study has limitations that should be noted. First, reduction accuracy usually needs to be verified by strict data. For the present study, only one set of clinical data was examined. Second, an OTA 61‐C1 fracture can generally be reduced very well. In contrast, OTA 61‐C2 and ‐C3 fractures are more difficult to reduce with the present technique, mainly because the reference frame cannot be inserted in the sacrum. Nonetheless, our preliminary research is promising, and we look forward to further demonstrating this new technique with more patients. Correspondingly, we are actively conducting additional experiments and trials to verify the effectiveness of this technology.

Conclusion

In this technical report, we describe a new technology using MRSN with a UCRT frame to assist pelvic fracture reduction and final definitive fixation. The present case series demonstrates that surgical navigation to reduce PRD is feasible, simple, and accurate. However, large multicenter samples are needed to further optimize the process, making the operation easier and the reduction more accurate.

Author Contributions

Jiaqi Li was responsible for the paper review and paper writing; Hua Chen and Peifu Tang were responsible for the study design; Chengla Yi and Haoyang Liu conceived and performed the surgery; Lin Qi followed up the patients and collected the clinical data; Ning Liu was responsible for the evaluation of the imaging data.

Conflict of Interest Statement

The authors declare that they have no conflicts of interest.

Ethics Statement

This study was approved by the ethics committee of the Chinese PLA General Hospital (301 Hospital). The approval number is S2021‐340‐01.

Acknowledgments

We would like to acknowledge all the staff involved in this work.

Jiaqi Li, Ning Liu these authors contributed to the work equally and should be regarded as co‐first authors.

Contributor Information

Hua Chen, Email: chenhua0270@126.com.

Peifu Tang, Email: tangpf301@163.com.

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