Fluoroscopy-guided vs. navigated iliosacral screw placement with intraoperative 3D scan or postoperative CT control: impact of the clinical workflow on patients` radiation exposure: Radiation exposure of different workflows for iliosacral screw placement

Different techniques are known to guide and verify safe placement of iliosacral screws (ISS). Fluoroscopy-guided (FSG) ISS placement or 3D navigation have provided similar results regarding accuracy of ISS insertion and rate of malpositioned screws in some studies, others showed improved accuracy for the navigated technique [1], [2], [3], [4].

Intraoperative 2D fluoroscopy as well as routine postoperative X-ray may not be reliable enough for an accurate analysis of fracture reduction and implant positions. Thus, some surgeons advocate for routine postoperative computed tomography (CT) to assess proper screw placement and fracture reduction [2,3,[5], [6], [7]]. C-arms with 3D capabilities may be used for navigated ISS placement [3,8]. Navigated surgery is an undoubtedly striking and very appealing technology. However, this technology is rather expensive, time consuming and not available everywhere. Thus, FSG ISS placement is still widely performed worldwide. However, higher radiation exposure for the conventional technique is a concern.

Even without navigation, intraoperative fluoroscopy-based 3D imaging is associated with some advantages compared to postoperative imaging. Most importantly, it provides the surgeon with the opportunity to detect and correct an insufficient fracture reduction or a malpositioned implant during the same procedure. Thus, the quality of the surgery may be improved and the rate of revision surgery reduced. Furthermore, postoperative imaging may become redundant. However, little is known about the radiation exposure of intraoperative 3D imaging systems compared to postoperative computed tomography (CT) in ISS placement.

It was the aim of this experimental study to evaluate radiation exposure for three different clinical workflows with a particular interest in comparing intraoperative 3D imaging and postoperative CT.

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