Cases

A 58-year-old woman sustained an intra-articular radius fracture in a fall. Initial treatment of this intra-articular displaced fracture consisted of closed reduction and percutanious k-wire fixation (see figure 1). Shortly after k-wire removal the patient began to experience disability of the wrist and severe pain. However, by  the time she seeked further treatment, she presented with a complex intra-articular malunion difficult to treat with traditional surgical techniques. Looking for a better alternative, the patient consulted Prof. Dr. Stockmans. With the help of SurgiCase Orthopaedics, a revolutionary software for virtual surgery planning, and patient-specific surgical guides he was able to reduce the surgery’s complexity drastically. As a result, the time spent in the operating room decreased considerably, while the outcome showed a substantial improvement over traditional techniques.

Visualizing the intra-articular pathology

Since traditional X-ray images contained too little information to provide a strong  foundation for diagnosis and treatment, a CT scan was made to get a better understanding of the malunion’s complexity. Still, the scope of the pathology was not completely understood as the intra-articular space could not be visualized. Importing the scans to SurgiCase Orthopaedics enabled Prof. Dr. Stockmans to look at the injury from three different angles: an axial view (already provided by the CT scan), a coronal and a sagittal view. What’s even more important, SurgiCase Orthopaedics allowed him to make a detailed 3D reconstruction of the individual bone fragments (see figure 2).  By doing so he could clearly see the intra-articular step-off of the malunion and of the different fragments. The 3D view revealed three fracture lines in the distal radius.

Pre-operative virtual surgery planning

SurgiCase Orthopaedics goes even further than that. It is our goal to make the surgeon’s life easier by giving him tools to perfect his pre-operative surgery planning. This will help him improve the surgical outcome. One of the main advantages here is the ability to test various surgical approaches before setting foot in the operating theatre. Since using SurgiCase Orthopaedics lessens the need for time-consuming, intraoperative  decision-making, it reduces actual surgery and recovery time.

In this case, Prof. Dr. Stockmans started with creating three planes through the original fracture lines. However, when he performed the virtual surgery in SurgiCase Orthopaedics, the software showed him this would damage the sigmoid notch severely and anatomical reduction of the fragments would need extra wedge osteotomies and bone grafting. The surgeon saw the failure of the traditional approach here, even before setting foot in the operating room. He then went for a new approach, perforating the bone by drilling a series of holes in close proximity on the original fracture lines. This would weaken the bone structure without damaging the sigmoid notch. After separating the different fragments in the software, an anatomical reduction of the different fragments proved to be feasible (see figure 3a and 3b).

Furthermore, showing the surgical planning to the patient convinced her of the accuracy of the new approach. Since an image is worth more than a thousand words, her belief in a successful outcome grew rapidly.

Risk reduction by using patient-specific surgical guides

Thanks to SurgiCase Orthopaedics, Prof. Dr. Stockmans knew in advance exactly what the pathology looked like. When he started the actual surgery, he stated that it felt like he had already been there before.

Transforming virtual surgery planning into a real-life operation still poses a certain amount of risk. When making the drill holes, it’s important to make sure that the drill goes along the predetermined path deep enough while at the same time you must prevent it from penetrating any underlying structures. Prof. Dr. Stockmans turned to Materialise to design and manufacture custom surgical guides based on his planning (see figure 4 and 5). This allows for an easy and accurate transfer of his planning into the operating room. Materialise’ patent pending, customized SurgiGuide drill guides make it possible to indicate exactly where you want the drill to enter the bone, but also to determine its angle, depth and exit point. These patient-specific guides, which are made of material that can be sterilized, have a unique fi t on the bone, thereby limiting the risk of error during surgery (see figure 6).

By using the SurgiGuide technique, it was easy to drill the necessary holes to weaken the bone. Next, Prof. Dr. Stockmans  separated the various bone fragments with a chisel, following the original fracture lines precisely. After separation, he moved them back to their anatomical position. That’s how SurgiCase Orthopaedics turned a very complex osteotomy into a conventional fracture reduction.

Four weeks after the surgery a visible improvement in the patient’s condition was noticed. Prior to entering the operating theatre, she had severe pain and only 20% mobility in her wrist. The surgery, performed with the use of patient-specific surgical guides, alleviated the pain and restored her wrist to full functionality (see figure 7).

The need for pre-operative planning for such a complicated pathology is clear. Performing the surgery described above without pre-planning and without the custom guides would have been extremely difficult. SurgiCase Orthopaedics was crucial for offering the surgeon a clear picture of the pathology before he began the operation. The combination of the rehearsal of the surgery beforehand and the use of the custom guides reduced the actual time spent in the operating room. Finally, thanks to these custom guides, the surgeon achieved greater accuracy than is possible with traditional techniques.