Computer-assisted surgery and planning in percutaneous pelvic screw fixation

Percutaneous pelvic screwing (PPS) enables fixation of traumatic or atraumatic fractures with little or no displacement, or displaced but reduced fractures, and preventive fixation of primary or secondary tumoral lesions. It is a relatively recent technique, and indications are evolving with progress in pre- and intra-operative imaging. Morbidity is lower than with open surgery. PPS is classically performed under fluoroscopy; computer-assisted surgery is of great interest, enabling analysis of safe bone corridors. Planning is based on image processing tools included in CT DICOM viewer packages. The aim of the present study was to review PPS. What are the indications for PPS? All pelvic ring fractures are in principle concerned if the reduction allows passage of a K-wire and then a screw. A distinction is to be made between, on the one hand, young patients, able to support a variable period of non-weight-bearing, in whom PPS stabilizes an unstable fracture, relieves pain on motion and prevents non-union, and, on the other hand, older patients for whom PPS enables optimally early resumption of weight-bearing. How to plan posterior PPS? The principal procedures are iliosacral screwing (ISS), trans-sacral screwing (TSS) and supra-acetabular screwing (SAS). How to plan anterior PPS? The principal procedures are anterior column/superior pubic ramus (AC/SPR) screwing, iliac wing screwing (IWS) and gluteal pillar screwing. How to plan percutaneous acetabular screwing (PAS)? The principal procedures are transverse acetabular screwing (TAS) and retrograde posterior column screwing (RPCS) or "butt screw". Fixation is demanding. PPS requires rigorous preoperative planning using CT DICOM viewer software. The principle consists in multiplane reconstruction of bone corridors, to assess the feasibility of PPS and analyze implant diameters, tracing lines to measure implant trajectory and length, and 3D reconstruction using the measurements, to assess entry and exit points and forecast intraoperative fluoroscopic views. What results, what complications, what innovations? Results are comparable to those of open surgery, with significantly less morbidity. The main complications are implant malpositioning and fixation failure, with secondary displacement of the fracture and/or implants. 3D printing, navigation and, recently, robotic surgery constitute the future of PPS. How PPS can go wrong? Difficulties or errors in planning, errors in patient positioning or errors in reading fluoroscopy are the main pitfalls. When available, intraoperative 3D imaging, associated to navigation or not, improves safety.