Anatomical conditions of the posterior pelvic ring regarding bisegmental transverse sacroiliac screw fixation: a 3D morphometric study of 125 pelvic CT datasets.

INTRODUCTION: Sacroiliac (SI) screws are used for osteosynthesis in unstable posterior pelvic ring injuries. In the cases of "sacral dysplasia", in which the elevated upper sacrum does not allow a secure SI screw insertion into the S1 level, the S2 segment must be used to achieve stable fixation. The bone quality of the S2 segment is thinner compared to that of the S1 vertebra and may cause biomechanical weakness. An additional SI screw insertion into the S3 level may improve stability. With respect to the anatomical conditions of the posterior pelvic ring, there have been no anatomical investigations to date regarding SI screw placement into the third sacral segment. MATERIALS AND METHODS: CT raw datasets from 125 patients (ø59 years, ø172 cm, ø76 kg) were post-processed using Amira 5.2 software to generate 3D pelvic models. A program code implemented in C++ computed a transverse bone corridor for the first, second and third sacral segments for a typical SI screw diameter of 7.3 mm. Volume, sagittal cross-section, iliac entrance area and length of the determined screw corridors were measured. A confidence interval of 95 % was assumed (p < 0.05). RESULTS: The fully automatic computation revealed a possible transverse insertion for one 7.3-mm screw in the third sacral segment in 30 cases (24 %). The rate (60 %) of feasible S3 screw placements in the cases of sacral dysplasia (n = 25) is significantly higher compared to that (15 %) of "normal" sacra (n = 100). With regard to the existence of transverse iliosacroiliac corridors as a function of sacral position in between the adjacent iliac bone bilaterally, a new classification of three different shape conditions can be made: caudad, intermediate minor, intermediate major, and cephalad sacrum. Gender, age, body height and body weight had no statistically significant influence on either possible screw insertion or on the calculated data of the corridors (p > 0.05). CONCLUSION: SI screw insertion into the third sacral level deserves discussion in the cases of sacral dysplasia. Biomechanical and practical utility must be verified.

Potentialities and limitations of a database constructing three-dimensional virtual bone models.

BACKGROUND: 3D bone reconstructions performed during general clinical practice are of limited use for preclinical research, education, and training purposes. For this reason, we are constructing a database of human 3D virtual bone models compiled from computer tomography (CT) scans. MATERIALS AND METHODS: CT data sets were post-processed using Amira(®) 5.2 software. In each cut, bone structures were isolated using semiautomatic labeling program codes. The software then generated extremely precise 3D bone models in STL format (standard triangulated language). These bone models offer a sustainable source of information for morphologic studies and investigations of biomechanical bony characteristics in complex anatomic regions. Regarding educational value and student acceptance models were introduced during bedside teaching and evaluated by medical students. RESULTS: The current database is comprised of 131 pelvises and 120 femurs (ø 60 years, ø 172 cm, ø 76 kg), and is continuously growing. To date, 3D morphometric analyses of the posterior ring and the acetabulum have been successfully completed. Eighty students (96 %) evaluated instruction with virtual 3D bone models as "good" or "very good". The majority of students want to increase learning with virtual bone models covering various regions and diseases. CONCLUSION: With consistent and steadily increasing case numbers, the database offers a sustainable alternative to human cadaver work for practical investigations. In addition, it offers a platform for education and training.

The influence of sacral morphology on the existence of secure S1 and S2 transverse bone corridors for iliosacroiliac screw fixation.

Sacroiliac (SI) screw fixation for unstable pelvic fractures stands out as the only minimally invasive method among all other ORIF procedures. A strictly transverse screw trajectory is needed for central or bilateral fracture patterns up to a complete iliosacroiliac fixation. However, secure screw insertion is aggravated by a narrow sacroiliac bone stock. This study investigates the influence of a highly variable sacral morphology to the existence of S1 and S2 transverse corridors. The analysis contained in this study is based on 125 CT datasets of intact human pelvises. First, sacral dysplasia was identified using the "lateral sacral triangle" method in a lateral 3-D semi-transparent pelvic view. Second, 3-D corridors for a 7.3mm screw in the upper two sacral levels were visualised using a proprietary IT workflow of custom-made programme scripts based on the Amira(®)-software. Shape-describing measurement variables were calculated as output variables. The results show a significant linear correlation between ratioT and the screw-limiting S1 isthmus height (Pearson coefficient of 0.84). A boundary ratio of 1.5 represented a positive predictive value of 96% for the existence of a transverse S1-corridor for at least one 7.3mm screw. In 100 out of 125 pelvises (80%), a sufficient S1 corridor existed, whereas in 124 specimens (99%), an S2 corridor was found. Statistics revealed significantly larger S1 and S2 corridors in males compared to females (p<0.05). However, no gender-related differences were observed for clinically relevant numbers of up to 3 screws in S1 and 1 screw in S2. The expanse of the S1 corridor is highly influenced by the dimensions of the dysplastic elevated upper sacrum, whereas the S2 corridor is not affected. Hence, in dysplastic pelvises, sacroiliac screw insertion should be recommended into the 2nd sacral segment. Our IT workflow for the automatic computation of 3-D corridors may assist in surgical pre-operative planning. Furthermore, the workflow could be implemented in computer-assisted surgery applications involving pelvic trauma.

The lateral sacral triangle--a decision support for secure transverse sacroiliac screw insertion.

Sacroiliac (SI) screw fixation represents an effective method to stabilise pelvic injuries. However, to date neither reliable radiological landmarks nor effective anatomical classifications of the sacrum exist. This study investigates the influence of variability in sacral shape on secure transverse SI-screw positioning. Furthermore, consistent correlations of these anatomical conditions are analysed with respect to standard planar pelvic views. For shape analysis, 80 human computed tomography data sets were segmented with the software Amira 4.2 to obtain 3D reconstructions. We identified anatomical conditions (ACs) according to the extent of the effect on the bony screw pathway. Subsequently, the pelvis was spatially aligned using representative bone protuberances in order to create standard Matta projections. In each view, the ACs were described in terms of distance from bone landmarks. Three-dimensional shape analysis revealed the height of the pedicular isthmus (PH) as the limiting variable for secure screw insertion. The lateral and outlet views allowed an orthogonal projection of PH. In the lateral view, the ratio of the lateral sacral triangle framed by the S1 body height and width showed a high correlation to PH (p = 0.0001). A boundary ratio of 1.5 represented a reliable variable to determine whether or not a screw can be inserted (positive predictive value: 97%). In the outlet view, the distance between the S1 endplate and the SI joint top level (EJ) strongly correlated with PH (p = 0.0001). With EJ 0 mm, screw insertion was possible in all cases (100%). SI-screw insertion requires a well-planned procedure. Orientation of the sacral pedicle is of extreme relevance. A narrow sacroiliac channel and high sacral shape variability limit secure screw placement. However, no determining parameters exist, allowing accurate prediction of secure screw insertion based on X-rays or fluoroscopy. The lateral sacral triangle in the lateral view represents a simple and accurate preoperative method of support for the surgeon's decision to undertake this procedure. No additional technical effort is necessary. A boundary ratio of 1.5 predicts a sufficient bone stock for at least one 7.3 mm screw. Furthermore, the evaluation of the outlet projection can be used to assess the safety of the operation. Basically, a preoperative lateral pelvic image should be mandatory.

Orbital form analysis: problems with design and positioning of precontoured orbital implants: a serial study using post-processed clinical CT data in unaffected orbits.

Inter-individual size and shape (form) variation for the orbital floor and medial wall was assessed and compared with its posterior partition. Reconstruction of the posterior partition is known to be a surgical challenge in complex orbital defect repair when using standard manual implant contouring and positioning techniques. The size variation of both regions was assessed, alone and combined, in statistical form analysis using three-dimensional computer models of left and mirrored right orbits, obtained from 70 clinical computed tomography (CT) scans of adult European Caucasians with unaffected orbits. Major shape and size variability for both regions was observed, but to a larger extent for the entire orbital floor and medial wall, with males having significantly larger regions but with no differing shape patterns. Statistical modeling was used to identify characteristic shape patterns in given orbits. The size, shape and positioning of precontoured implants are decisive criteria for the adequate repair of complex orbital defects. The results indicate that optimal form conditions for prefabricated implants exist in a restricted area corresponding to the transition of the posterior orbital floor and medial wall.