Using of computer assisted patient specific instruments to help percutaneous fixation of fractures and dislocations of bone and joints.
Percutaneous fixation of fractures is usually done under x-ray (C arm) control with excessive exposure to radiation and no guidance of perfect positioning. Achieving the correct trajectory and placement of the wire for the percutaneous fixation of fractures needs to know the exact points of insertion, direction and the angle of the wire. However, the percutaneous approach has fewer complications than the open and/or dorsal approaches.
The bone anatomy and location makes percutaneous wire insertion a complicated process. The percutaneous fixation of fractures has a long learning curve, furthermore the patient has exposed to prolonged radiographic exposure in the time that the surgeon tries to guide the wire to the correct position.
The challenge of the percutaneous fixation of fractures is to reduce the amount of radiation exposure for both the patient and the surgeon.
More complications were founded in using the technique of percutaneous fixation of fractures in the cases of acetabular fractures, proximal humours fractures, scaphoid fractures due to the bone geometry, location, degree of comminution, and bone quality. Nevertheless, percutaneous fixation of fractures is a highly recommended in many cases of fractures than the other techniques like plate fixation, joint replacement and/or intramedullary nailing.
In this invention, the technique of the computer assisted surgery is used to build and design a patient specific surgical guide for percutaneous fixation of fractures. It aims to get an accurate positioning of wires or implants in bone through percutaneous applications. The technique based on the preoperative planning to observe the exact points of insertion, direction and the angle of the wire and/or screws. Percutaneous fixation of fractures and dislocations is applicable to any bone and joints that palpable and easily detectable through the skin. By using of surface anatomy, it is possible to identify custom bony landmarks, these rigid fixed structure are seen in CT scan and planning of the surgery can be done preoperatively based on these landmarks. When one or more of these landmarks are broken and displaced, other nearby landmarks are used to guide the reduction.
A 3D model of the bone was created on the 3D modelling software based on the 2D images captured from the X-ray, CT-scan and Ultrasound. The 2D images of the both the bony land marks and skin collected by a potable 3D scanner with mechanical touch probe and saved in Dicom format. The CT-scan collect the data of the bone (hard tissues) and the ultrasound imaging collect the data of the skin and soft tissues. At this moment, we have a complete view and a complete data for the skin, soft tissues and bone landmarks (e.g. styloid process of radius, ulna head, olecranon, spinous process, tibial tuberosity, lateral malleolus, medial malleolus, fibula head, . . . ). These data will be inserted to the image processing software to create the 3D model of the bone.
The second phase of this technique is to design the patient specific surgical guide for percutaneous fixation of fractures. This guide allows the surgeons to detect the best and accurate insertion point and direction of the wires as well the surgery will be minimally invasive.
The guide will be used as a patient-specific surgical guide for percutaneous fixation of fractures, dislocation and osteotomies of bony structures that are palpable under the skin, the guide designed for detection of the point of insertion and trajectory of metal-ware (wires, screws, plates or nails). The guide consisting of different parts, that will be assembled together in different shapes according to according to the location and orientation of the fractures of like: clavicle, proximal humerus, distal humerus, proximal radius and ulna, distal radius and ulna, hand bones, clavicle, patella, distal fibula, medial malleolus, spine or feet bones. The guide produced from a radiolucent material and it does not interfere with imaging if needed. The guide should be rigid to allow manipulation without bending. The manufacturing material is Nylon P12 or Nylon P11.
The guide comprising of a reduction arc (3), detachable accessory rods [(27) and (28)] and percutaneous wire guiding sleeves [(6), (7) and (24)]. The reduction arc has a several holes in its body (29), these holes are an assembly holes. The detachable accessory rods seating introducers [(27) and (28)] are attached and de-attached to the reduction arc by inserting the circular ends of these rods inside the assembly holes in reduction arc body.
The reduction arc has a two spherical ends which are [(1) and (2)], the function of these introducers is to seat over the skin on the bony landmarks in a single and secure position to fix the guide over the bone. The internal surface (19) of these seating introducers have the same anatomy shape like the bony landmark, which is mean it will fit in its position over the bone.
The lateral pointed introducer (1) seated on the lateral bone landmark, while the medial pointed introducer (2) seated on the medial bone landmark.
Also, the detachable accessory rods [(27) and (28)] have seating introducers [(4) and (5)] at its ends. The function seating introducers [(4) and (5)] is same as the seating introducers which are located at the ends of the reduction arc. It seated on the bony landmarks on the damaged bone. the detachable accessory rods [(27) and (28)] provide an additional stability to the guide over the bone. The medial detachable accessory rod (27) seated on the medial bone landmarks like the ulna or fibula; while the lateral detachable accessory rod (28) seated on the lateral bone landmarks like the radius, tibia or olecranon. That means, the patient-specific surgical guide seated on a bony landmark wherein the internal surface (19) of the seating introducers [(1), (2), (4) and (5)] matches the surface anatomy of bones and fit in a single secure position for the reduction of bone or joint displacement and to insert wires or metal ware in bone and joints without need for fluoroscopic imaging.
In case of lateral fractures like distal fibula and distal ulna fractures, the surgeon attached only the lateral detachable accessory rod (28) to the reduction arc (3), there is no need to use the medial one (27). And vice versa, In case of medial fractures like distal humerus and medial malleolus fractures, the surgeon attached only the medial detachable accessory rod (27) to the reduction arc (3), there is no need to use the lateral one (28).
In case of the extendable fractures like the distal radius fracture, the surgeon should be attached the lateral and the medial detachable accessory rod (28) and (27) to the reduction arc (3) to secure the position of the guide over the bone.
For the distal radius fracture, the medial and the lateral detachable accessory rods ((27) and (28)) assemble to the reduction arc and seated on the radius bone and ulna bone respectively. Wherein in the distal humerus fracture, the medial detachable accessory rod (27) assembled to the reduction arc and seated on the olecranon bone. In the medial malleolus fracture, the medial detachable accessory rod (27) assembled to the reduction arc and seated on the tibia bone. In case of the fibula fracture, the lateral detachable accessory rod (28) assembled to the reduction arc and seated on the fibula bone. In the case of pedicle screw fixation for spinal fractures fixation or fusion or other spinal surgery, the surgeon assembles the medial and the lateral detachable accessory rods ((27) and (28)) to the reduction arc and seated on at least two of the percutaneous landmarks like spinous processes and transverse processes.
The seating introducers [(1) and (2)] have a primary fastening holes (10) and the seating introducers [(4) and (5)] have a secondary fastening holes (8). These fastening holes used for fixing the guide over the bone by using of surgical pins and/or wire. This process will give the guide an additional stability and rigidity over the bone and allows the surgeon to insert the percutaneous wires to fix the fractures easily, especially for the low-experience surgeons who didn't have experience with this kind of surgeries.
The guide has percutaneous wire guiding sleeves [(6), (7) and (24)]. All of these sleeves are cannulated to directed the wires through the internal hole in the percutaneous wire guiding sleeve to determine and detection the point of insertion and trajectory of metal-ware (wires, screws, plates or nails) in the bone to fix the displaced fractures. These sleeves are located medially and/or laterally to fix the fractures of distal radius, distal humerus, fibula fractures and medial malleolus fractures from both of the medial and lateral sides.
According to the orientation and location of the fracture, the surgeon has the ability to use one or more of these sleeve as follows:
The reduction arc (3) consisting of two parts with a gap between the parts, the gap introduces the reduction indicator (15); when the surgeon inserts the percutaneous wire through the cannulated percutaneous wire guiding sleeve to fix the fracture, the two parts of the reduction arc will move to each other and when the two parts meet together at the final position (16), it means the displaced fracture is reduced.
The seating introducers [(1), (2), (4) and (5)] detect the positions of the fiducial markers that were inserted on the bone preoperatively, these markers are additional landmarks during surgery for a certain structures of bone when the landmarks are hidden due to opacity. While, the percutaneous wire guiding sleeves directed the percutaneous pins to make some hidden landmarks visible or prominent.
Filing Document | Filing Date | Country | Kind |
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PCT/EG2020/000020 | 8/11/2020 | WO |