Intraoperative 3D imaging reassures traumatologists at the University of Virginia Medical Center (UVA).
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Surgical standard procedures requiring treatment control utilizing postoperative CT scans can be enhanced regarding both procedural and ultimately economic outcome if possible complications can be disclosed while the patient is still on the table. Intraoperative real-time rotational imaging as provided in a hybrid operating room has already proven to be key to making this happen. This technological advance can result in a decrease in complications associated with limb malalignment and the ability to provide fracture treatment in a more individualized and cost-effective manner.
UVA medical center has been involved with computer-assisted orthopedic surgery since the early ‘90s. Orthopedic Traumatologist David Kahler is a pioneer in the field. Seth Yarboro specializes in pelvis and lower extremity trauma including bone non-unions and malalignment surgery. Bobby Chhabra is the Chair of Orthopedic Surgery at the University of Virginia Health System.
“Using the Artis zeego the 2D imaging is most helpful when we’re looking at long bones. It has a very large field of view, which gives us the ability to image the entire bone.”
How would you define a hybrid operating room?
B. CHHABRA: There are three different types of hybrid rooms, but in our case the hybrid operating room is an imaging suite as well. With Artis zeego it’s like having a CT scanner right in the OR, so we have full imaging capability to provide the highest level of care.
Can a hybrid OR really increase quality of care?
D. KAHLER: The goal of minimally invasive surgery is to get better imaging. Since we aren’t seeing as much of the patient’s anatomy we have to rely on the imaging to give us the information we need.
B. CHHABRA: The technology in the hybrid room allows you to get a true 3D representation, a complete picture of a long bone, the pelvis, or the spine so that you can repair an injury and place your implants exactly where they need to be. You can feel confident that you are obtaining a precise result, because the imaging is performed in real time intraoperatively. You do not have to wait for X-rays after surgery in the recovery room to make sure that your fracture alignment and implant placement is correct.
“One of the goals of an institution like mine is to be an innovative leader in the newest technologies that will advance patient care.”
D. KAHLER: Just having the confidence when you leave the operating room, knowing you did exactly what you planned to do, and have confirmation of that is a major advance in our field. Even to look at the leg lengths of the patient and the rotation of the hips compared to the knees to make sure that the alignment is correct. These are things we simply couldn’t do before in the operating room. Precision is what’s provided with the hybrid operating room: you can place your implants exactly where you want them and be confident that they are accurately placed. This precision allows you to limit your surgical incisions. You don’t have to make large incisions where there’s more potential for blood loss, more potential for muscle stripping and muscle dissection, which could impact the pace of rehab. There are several complications you can avoid with this technology.
“Precision is what’s provided with the hybrid OR: you can place your implants exactly where you want them and be confident that they are there.”
Specifically what procedures use the intraoperative 3D at UVA?
S. YARBORO: We use intraoperative 3D imaging for pelvis and acetabulum surgeries where we have a difficult time determining exactly where implants should be placed. Two other procedures we use the technology for routinely are intra-articular fractures where we want to have the three-dimensional imaging after all the implants are in place to confirm anatomic alignment of the joint surface and appropriate position of the implant. Also syndesmotic injuries of the ankle where the fibula is displaced relative to the tibia can be difficult to treat with precise alignment without 3D imaging.
B. CHHABRA: 2D imaging is limited because you are looking at a bone in two planes and you do not get the exact information that is needed to treat many injuries. Often fracture patterns are in three planes and if you’re only getting two images, you’re not getting a full picture of the fracture and you cannot align it as perfectly as possible when you’re limited by your image quality.
And then how do you think this affects the patient outcome?B. CHHABRA: You can obtain 3D images so that you know that your fractures are aligned well, that your implants are in the right position, with the goal of doing the perfect surgery with minimal incisions. It is really a phenomenal advance in treatment of these orthopedic trauma injuries.
D. KAHLER: It’s one-stop shopping. We try to get everything done in one trip to the operating room. There are no surprises when we get a post-op CT scan: when we see a screw that’s a little bit too long or perhaps one that’s malpositioned that has to be changed. Up to 20 percent of the time, we are going to make a change if we have that information in the operating room. So it’s a huge advantage to the patient.
We guess, some people have been against the 3D imaging …
S. YARBORO: I can certainly understand some resistance to the change that would be involved with adopting this new technology. But there are cases that present particular imaging difficulties and that’s where we found it to be most helpful. It’s not to be used necessarily routinely but for certain instances it can really make a dramatic difference in outcome.
B. CHHABRA: I think one of the goals of an institution like mine is to be an innovative leader in the newest technologies that will advance patient care. It will be a great benefit to any institution to learn how to use high-level technologies like this that have a major potential for improving the outcomes of surgical intervention and reducing complications.
What is your vision for orthopedic trauma surgery?
B. CHHABRA: There are so many opportunities to improve our patient outcomes, particularly in the trauma population. Having information is crucial in the treatment of any patient. I think the hybrid OR is a step in that direction that provides us the information we need to best treat complex injuries.
D. KAHLER: I think the real Holy Grail is the ability to do a fracture reduction in the operating room, confirm the position with 3D imaging, and once we’re satisfied with the result, to be able to actually navigate and place an implant and lock it in place with screws to hold the fracture in place while it heals. And we’re very close to achieving this level of precision in fracture care.
What advice can you give to a decision maker planning to integrate a hybrid OR at the hospital?
B. CHHABRA: Radiation safety is a very important issue that needs to be addressed. Everyone in the room has to be safe from excessive radiation exposure. Having the right equipment and having surgeons who are trained on this technology are both very critical in optimizing the use of a hybrid OR.
S. YARBORO: The main thing that I would recommend is from a very early point involving multiple disciplines – the vascular teams, the cardiothoracic team, neurosurgery, orthopedics – so that you can have multiple services that use the new technology.
D. KAHLER: Having an integrated hybrid OR in the operating room setting, I think is a real advantage. And I can’t say with any certainty at this time that the investment will pay for itself, but we are seeing benefits now for our patients.
B. CHHABRA: If these technologies are shown to result in better patient outcomes, then the surgeons who adopt them will be leaders in their fields.
UVA Health System in Charlottesville, Virginia, includes a hospital, nationally recognized cancer and heart centers, and primary and specialty clinics throughout central Virginia. Its level-one trauma center has a large referral basis from all over the state and treats some of the more significant injuries in the area.