Robot-assisted Percutaneous Cannulated Screw Fixation of Femoral Neck Fractures: Preliminary Clinical Results.

OBJECTIVE: To assess the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of femoral neck fractures. METHODS: From September 2015 to July 2017, 26 patients with unilateral femoral neck fractures were treated with TiRobot-assisted percutaneous cannulated screw fixation. The femoral necks were fixed using three cannulated screws with robot assistance applying the following procedure: image acquisition, path planning, and needle and screw placement. The results of the treatment, including operation duration, frequency of fluoroscopy use, implant placement accuracy, intraoperative bleeding, total drilling, surgical complications, fracture healing time, fracture healing rate, and Harris scores at the last follow-up, were recorded and compared with 23 similar patients who underwent conventional manual positioning surgery. RESULTS: A total of 147 cannulated screws were placed in all patients. The TiRobot group had shorter operation duration (62.6 ± 8.7 min vs 72.4 ± 10.3 min) and fracture healing time (5.1 ± 2.4 months vs 5.9 ± 2.8 months) than the conventional group (P > 0.05). The robot group had significantly less use of fluoroscopy (26.5 ± 7.4 times vs 51.3 ± 9.4 times), intraoperative bleeding (8.2 ± 5.3 mL vs 36.4 ± 12.5 mL), and total drilling (9.4 ± 4.2 times vs 18.3 ± 9.1 times) than the conventional group (all P < 0.05). The screw parallelism was significantly improved (24.0 ± 0.6 points vs 21.5 ± 1.2 points) and the neck-width coverage (72.0 ± 6.7 mm2 vs 53.8 ± 10.4 mm2 ) was significantly enlarged compared to the conventional group (P < 0.05). Only three guiding needles were used to penetrate the femoral head during manual insertion in the TiRobot group, which was significantly lower than that in the conventional group (3/78, 3.8% vs 9/69, 13.0%; P < 0.05). Other complications such as wound infection, vascular or nerve injury, screw loosening, and secondary screw displacement, did not occur in the two groups. There was no significant difference between the two groups in fracture healing rate (88.4% vs 82.6%) and Harris scores at the last follow up (88.2 ± 3.6 points vs 87.3 ± 4.7 points; P > 0.05). CONCLUSION: TiRobot-assisted percutaneous cannulated screw fixation of femoral neck fractures is advantageous over conventional surgery with manual positioning due to easier manipulation, more accurate screw insertion, less invasion, and less radiation exposure, suggesting that it is a better method to stabilize femoral neck fractures.

Robot-assisted Minimally-invasive Internal Fixation of Pelvic Ring Injuries: A Single-center Experience.

OBJECTIVE: To investigate the indications, surgical strategy and techniques, safety, and efficacy of robot-assisted minimally-invasive internal fixation of pelvic ring injuries. METHODS: The clinical data of 86 patients with anterior and posterior pelvic ring injuries who underwent robot-assisted minimally-invasive internal fixation were retrospectively analyzed. The patients included 57 men and 29 women aged between 22 and 75 years, with an average age of (40.2 ± 13.6) years. According to the Tile classification, there were 5 (5.8%) type A2, 48 (55.8%) type B, and 33 (38.4%) type C fractures. The surgical plans were formulated based on the injury type of the pelvic ring, the effectiveness of the reduction, and the integrity of the osseous channel. Posterior pelvic ring injuries were treated with robot-assisted percutaneous cannulated screw fixation of the sacroiliac joint. Anterior pelvic ring injuries were treated with robot-assisted percutaneous cannulated screw fixation of the pubic ramus, INFIX fixation, or a "hybrid" fixation. The surgical complications and the efficacy of the surgical treatments were analyzed. RESULTS: A total of 274 screws were inserted with robotic assistance, of which 262 screws were successfully inserted to a satisfactory position on the first attempt. The number of screws placed per person was 3.2 on average, and the average operation time was 175 min (35-280 min). Fluoroscopies were performed an average of 29.1 times (range, 9-63 times), and it took 6.1 s to place each screw. There were 13 unsatisfactory guiding needle placements during the surgeries, among 7 of which cutting or penetration of the cortex was re-planned until satisfactory insertions; 1 penetrated the pubic cortex, causing hemorrhage of the "crown of death," and was changed to "hybrid surgery". The robot-assisted surgical wounds all healed by primary intention with satisfactory position and precision of screw insertions. All patients were followed up for 3-6 months, with an average of 4.2 months. There were two postoperative fixation failures, in which both patients had separated symphysis pubes after hybrid surgery. The average Majeed score at the last follow-up was 92.4 points. CONCLUSIONS: Robot-assisted surgery is accurate and minimally invasive, with a high success rate for one-time screw placement and satisfactory clinical results. The indications and surgical strategy should be rigorously selected, the level of surgical techniques mastered, and the operating procedures standardized, all of which may help to prevent surgical complications. Robot-assisted surgery provides a novel modality for the minimally-invasive treatment of pelvic ring injuries.

Robot-assisted percutaneous screw placement combined with pelvic internal fixator for minimally invasive treatment of unstable pelvic ring fractures.

PURPOSE: The purpose of this study was to investigate the safety and efficacy of the combination of robot-assisted percutaneous screw placement and pelvic internal fixator (INFIX) for minimally invasive treatment of unstable anterior and posterior pelvic ring injuries. METHODS: From September 2016 to June 2017, twenty-four patients with unstable anterior and posterior pelvic ring injuries were treated with TiRobot-assisted percutaneous sacroiliac cannulated screw fixation on the posterior pelvic ring combined with robot-assisted pedicle screw placement in the anterior inferior iliac spine along with INFIX on the anterior pelvic ring. The results of the treatment, including surgery duration, fluoroscopy frequency, total drilling, amount of blood loss, fracture healing time, and postoperative functional outcomes were recorded and compared with another 21 similar patients who underwent conventional manual positioning surgery. RESULTS: The TiRobot group incurred significantly shorter duration of surgery; less fluoroscopy frequency, intraoperative bleeding, and total drilling than in the conventional group (P < 0.05). Postoperative radiological follow-up showed that all screws were in the safe area and no screw penetrated the cortex. All wounds healed by primary intention and no iatrogenic damage to the blood vessels, nerves, and organs occurred. Patients showed good tolerance to INFIX and reported no discomfort. The mean follow-up duration was 5.4 months; the fractures were all healed, no loss of reduction occurred, and the mean Majeed score at the last follow-up did not show any difference. CONCLUSION: TiRobot-assisted percutaneous screw placement combined with INFIX for the anterior and posterior pelvic ring injuries is accurate, safe, less invasive, and shows satisfactory efficacy, suggesting it is a better method for minimally invasive treatment of unstable pelvic ring fractures.

Removal of Benign Superficial Masses Using the TriVex System: Preliminary Clinical Results.

BACKGROUND AND OBJECTIVE: Transilluminated powered phlebectomy using the TriVex system is a new procedure for minimally invasive varicose vein surgery. We used the TriVex system for the removal of benign superficial subcutaneous soft tissue masses, and we also achieved satisfactory clinical effects. The objective of this study was to explore the feasibility, benefits, and technique-related complications of using the TriVex system for the removal of benign superficial masses as a novel and minimally invasive surgical technique. METHOD: Between January 2010 and August 2016, 452 patients with benign superficial soft tissue masses underwent surgical removal of masses using the TriVex II system in our department. The surgical complications, postoperative cosmetic outcome, and personal satisfaction were reviewed at a mean follow-up of 24 months. RESULTS: The TriVex procedure was successfully completed in all patients using only local tumescent anesthesia without any technical problem and serious complications. The mean operation duration was 8.5 minutes, and the average blood loss was 5 mL. Surgical complications were observed in 69 cases (15.3%) of subcutaneous ecchymosis, 34 cases (7.5%) of skin perforation, 14 cases (3.1%) of subcutaneous hematoma, 13 cases (2.9%) of wound infection, and 7 cases (1.5%) of induration of operation area. Eleven patients (2.4%) showed recurrence during the follow-up and were cured by reoperation by the TriVex system. Overall, the majority of patients (N = 436, 96.5%) were very satisfied or satisfied with the outcome. CONCLUSION: The TriVex procedure for the removal of benign superficial masses is simple, safe, and effective with advantages of short operation time, small incisions, and good cosmetic outcome, which is predicted as a new minimally invasive surgery of superficial masses.

Prosthetic Mesh Repair in the Emergency Management of Acutely Strangulated Groin Hernias with Grade I Bowel Necrosis: A Rational Choice.

The aim of this study was to determine the feasibility of prosthetic mesh repair according to the degree of bowel necrosis in the emergency management of acutely strangulated groin hernias. Emergency prosthetic mesh repair versus primary suture repair was randomly performed in 208 consecutive strangulated groin hernia patients with bowel necrosis between January 2005 and August 2016. The degree of bowel necrosis of each patient was determined according to a modified three-grade classification system. Patient characteristics sorted by repair method were analyzed by using Pearson's chi-squared tests. Correlations between mortality and wound-related morbidity with bowel necrosis grade and repair method were analyzed. There was no difference in gender, age, body mass index, comorbid diseases, hernia type (left or right, primary or recurrent), necrosis grade, and mortality between the mesh repair and suture repair groups (all P > 0.05). However, with regard to wound-related morbidity, there was significant difference between the two groups (P < 0.05). Mortality and wound-related morbidity showed significant relationship with necrosis grade, especially with regard to postoperative wound infection (P < 0.001). The wound infection rate with mesh repair was significantly higher than that with primary suture in Grade II and III necrosis patients (P < 0.05), but there was no difference in Grade I patients (P > 0.05). The use of prosthetic mesh in the emergency repair of acutely strangulated groin hernias seems to be as safe as suture-only repair in patients with noninfected strangulated bowel (Grade I necrosis). The use of prosthetic mesh repair is a rational choice made based on the degree of bowel necrosis in the emergency management of acutely strangulated hernias.

A novel bowel necrosis classification system and examination of patient outcomes in incarcerated groin hernia patients.

The objective of this study was to determine a classification system for BN in incarcerated groin hernia patients and to explore the possible relationship between BN staging and patient outcomes. Incarcerated groin hernia patients treated with emergency bowel resection from January 2008 to December 2013 were screened for inclusion in a prospective study. A novel three-stage classification system was proposed for BN (BN stages I-III) and correlations between adverse events (AEs) and mortality with BN stage were determined. A total of 108 patients were included, with 71, 26, and 11 patients in BN stages I, II, and III, respectively. AEs, which included wound and intra-abdominal infections and other systemic complications, increased with higher BN stage (all P < 0.05). Mortality increased with BN stage, with 2.8%, 7.7%, and 27.3% at BN stages I, II, and III, respectively (P < 0.05). The proposed BN staging system can objectively reflect the degree of bowel damage and its corresponding adverse outcomes.

Classifications of clinical and bowel morphological changes and their relationship with characteristics of patients with incarcerated groin hernias.

BACKGROUND: There is currently no grading standard for the degree of clinical and bowel morphological changes. The objective of this study was to define clinical and bowel morphological classifications and investigate the possible relationship with the characteristics of patients with incarcerated groin hernias. MATERIAL AND METHODS: We retrospectively studied 195 patients who underwent emergency hernia repair with simultaneous bowel resection between January 1992 and January 2012. We classified the degree of clinical and bowel morphological changes into 3 grades based on the incarceration time, intestinal morphology after damage, hernia sac integrity, degree of inflammation, and the presence/absence of bacterial growth, peritonitis signs, mechanical obstruction, cellulitis, and systemic shock. We also recorded patient characteristics and analyzed their relationships with these degrees according to our grading system. RESULTS: We identified 134, 42, and 19 cases of Grades I, II, and III of clinical and bowel morphological changes, respectively. Pearson's chi-squared tests revealed that advanced age (P=0.001), presence of comorbid disease (P=0.002), and high American Society of Anesthesiologists (ASA) score (P=0.017) were related to the degree. Morbidity and mortality also showed significant relationships with the degree (P<0.001, P=0.005, respectively), especially with regard to post-operative infection. CONCLUSIONS: The proposed 3-stage classifications of clinical and bowel morphological changes can be used to objectively reflect the degree of bowel damage. Greater levels of the changes were associated with higher incidences of complications and increased mortality, especially for older patients with comorbid diseases and poor ASA scores. Urgent surgery should be performed to avoid bowel damage exacerbation.

Trephine arthrodesis of subtalar joints: operative technique and clinical effect.

OBJECTIVE: To review the operative technique of trephine arthrodesis of subtalar joints and evaluate its clinical effect. METHODS: From June 1998 to October 2006, we performed subtalar arthrodesis on 38 feet of 34 patients for a variety of painful disorders of hindfoot with trephine technique. Clinical and radiologic follow-up evaluations were performed for 45 months on average (range, 21 to 110 months) after arthrodesis. RESULTS: No severe complications were found in this study except one patient with dropfoot and two with skin necrosis. The average ankle-hindfoot scores of the American Orthopaedic Foot and Ankle Society (AOFAS) was improved from 48.3 preoperatively to 79.2 postoperatively (P<0.05). The pain scores of visual analogue scales (VAS) decreased from 7.2 (range, 3 to 10) preoperatively to 2.6 (range, 1 to 6) postoperatively (P<0.05). Subjectively, the patients experienced improvements in pain, function, cosmesis, and shoewearing. Overall, 30 patients were satisfied and all patients would have this procedure again under similar circumstances. Postoperative radiology showed that complete union was found in 35 feet 6 months after operation, with the successful union rate of 92.1%. There was an increase in arthritic scores for 5 ankles, 4 talonavicular joints, 4 calcaneocuboid joints, and 4 midfoot joints. Nonunion occurred in 3 subtalar joints with anterolateral approach, which required revision arthrodesis. CONCLUSION: Isolated subtalar arthrodesis with trephine method is an effective procedure for painful malalignment of hindfoot.