Screw Placement for Acetabular Fractures: Which Navigation Modality (2-Dimensional vs. 3-Dimensional) Should Be Used? An Experimental Study

Objectives: Screw navigation techniques with different image guidance [2-dimensional (2D) vs. 3-dimensional (3D) fluoroscopy] were evaluated for acetabular fracture surgery. Methods: Two-dimensional and 3D navigation images were analyzed for visualization of different osseous corridors: supra-acetabular, anterior column, posterior column, and infra-acetabular. Forty guide wires per group were placed in synthetic pelvis with a prefabricated soft tissue envelope (10 per group) using a 2D or 3D fluoroscopic navigation procedure. Duration of the single steps for each procedure and of cumulative fluoroscopy time was measured. The accuracy of guide wire placement was evaluated visually and in 3D cone-beam scans. Results: The overall procedure time per pelvis was significantly reduced in the 3D group compared with the 2D group [mean +/- standard error (SE) (minutes): 50.11 +/- 1.38 vs. 63.42 +/- 2.32; P < 0.0001]. A trend to reduction in image acquisition time [mean +/- SE (minutes): 12.37 +/- 1.34 vs. 15.43 +/- 1.03; P = not significant] and significant increase in the cumulative fluoroscopy time [mean +/- SE (seconds): 64 +/- 9 vs. 13 +/- 1.3; P < 0.0001) was measured in the 3D compared with the 2D group, caused by the 3D scan. Intra-articular misplacements were not observed in both the groups, but an increased accuracy could be achieved using the 3D image-based navigation procedure (perfect placement: 37 vs. 29; secure placement: 2 vs. 7; misplacement: 1 vs. 4). Conclusions: Both navigation procedures securely prevent an intra-articular penetration during drilling, but the 3D image-based navigation procedure increases the overall accuracy compared with the 2D image-based navigation technique (misplacement rates of 2.5% vs. 10%). Especially, in very narrow corridors (as the infra-acetabular screw path), the use of 3D navigation should be preferred.