Name: a teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation technique
Uploaded: 2023-01-06T14:00:00
Description: Watch this Scientific Journal Video about A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique at JoVE.com

The application of this robotic technique was approved by the ethics committee of the Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, and it complies with the Helsinki Declaration of 1975, as revised in 2013.
1. Preoperative planning
<ol>
	<li>Fix the cadaveric pelves in the supine position using a fluoroscopic plate base (see Table of Materials) by inserting two Schanz pins through the femur. In the supine position,...

<ol>
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J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+percutaneous+cannulated+screw+fixation+of+femoral+neck+fractures:+Preliminary+clinical+results.">Robot-assisted percutaneous cannulated screw fixation of femoral neck fractures: Preliminary clinical results.</a> Orthopaedic Surgery. 11 (1), 34-41 (2019).</li><li>Lei, H., Sheng, L., Manyi, W., Junqiang, W., Wenyong, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+biplanar+robot+navigation+system+for+the+distal+locking+of+intramedullary+nails.">A biplanar robot navigation system for the distal locking of intramedullary nails.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 6 (1), 61-65 (2010).</li><li>Oszwald, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotized+access+to+the+medullary+cavity+for+intramedullary+nailing+of+the+femur.">Robotized access to the medullary cavity for intramedullary nailing of the femur.</a> Technology and Health Care. 18 (3), 173-180 (2010).</li><li>Hung, S. S., Lee, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+assessment+of+a+surgical+robot+for+reduction+of+lower+limb+fractures.">Functional assessment of a surgical robot for reduction of lower limb fractures.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 6 (4), 413-421 (2010).</li><li>Dagnino, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Image-guided+surgical+robotic+system+for+percutaneous+reduction+of+joint+fractures.">Image-guided surgical robotic system for percutaneous reduction of joint fractures.</a> Annual Review of Biomedical Engineering. 45 (11), 2648-2662 (2017).</li><li>Garcia, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trauma+Pod:+A+semi-automated+telerobotic+surgical+system.">Trauma Pod: A semi-automated telerobotic surgical system.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 5 (2), 136-146 (2009).</li><li>Gaensslen, A., M&#252;ller, M., Nerlich, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Acetabular Fractures: Diagnosis, Indications, Treatment Strategies. , (2017).</li><li>LBR Med: A collaborative robot for medical applications. KUKA Available from: <a target="_blank" href="https://www.kuka.com/en-cn/industries/health-care/kuka-medical-robotics/lbr-med">https://www.kuka.com/en-cn/industries/health-care/kuka-medical-robotics/lbr-med</a> (2023)</li><li>Gras, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=2D-fluoroscopic+navigated+percutaneous+screw+fixation+of+pelvic+ring+injuries--A+case+series.">2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries--A case series.</a> BMC Musculoskeletal Disorders. 11, 153 (2010).</li><li>Innocenti, B., Bori, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotics+in+orthopaedic+surgery:+Why,+what+and+how.">Robotics in orthopaedic surgery: Why, what and how.</a> Archives of Orthopaedic and Trauma Surgery. 141 (12), 2035-2042 (2021).</li><li>Chen, A. F., Kazarian, G. S., Jessop, G. W., Makhdom, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+technology+in+orthopaedic+surgery.">Robotic technology in orthopaedic surgery.</a> Journal of Bone and Joint Surgery. 100 (22), 1984-1992 (2018).</li><li>D'Souza, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+spine+surgery:+History,+efficacy,+cost,+and+future+trends.">Robotic-assisted spine surgery: History, efficacy, cost, and future trends.</a> Robotic surgery. 6, 9-23 (2019).</li><li>Dagnino, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Navigation+system+for+robot-assisted+intra-articular+lower-limb+fracture+surgery.">Navigation system for robot-assisted intra-articular lower-limb fracture surgery.</a> International Journal for Computer Assisted Radiology and Surgery. 11 (10), 1831-1843 (2016).</li><li>F&#252;chtmeier, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduction+of+femoral+shaft+fractures+in+vitro+by+a+new+developed+reduction+robot+system+'RepoRobo.">Reduction of femoral shaft fractures in vitro by a new developed reduction robot system 'RepoRobo.</a> Injury. 35, 113-119 (2004).</li><li>Schuijt, H. J., Hundersmarck, D., Smeeing, D. P. J., vander Velde, D., Weaver, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+fracture+fixation+in+orthopaedic+trauma+surgery:+A+systematic+review.">Robot-assisted fracture fixation in orthopaedic trauma surgery: A systematic review.</a> OTA International. 4 (4), 153 (2021).</li><li>Wang, J. Q., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+sacroiliac+screw+placement:+A+prospective+randomized+comparison+of+robot-assisted+navigation+procedures+with+a+conventional+technique.">Percutaneous sacroiliac screw placement: A prospective randomized comparison of robot-assisted navigation procedures with a conventional technique.</a> Chinese Medical Journal. 130 (21), 2527-2534 (2017).</li><li>Zhu, Z. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=TiRobot-assisted+percutaneous+cannulated+screw+fixation+in+the+treatment+of+femoral+neck+fractures:+A+minimum+2-year+follow-up+of+50+patients.">TiRobot-assisted percutaneous cannulated screw fixation in the treatment of femoral neck fractures: A minimum 2-year follow-up of 50 patients.</a> Orthopaedic Surgery. 13 (1), 244-252 (2021).</li><li>Gardner, M. J., Routt, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transiliac-transsacral+screws+for+posterior+pelvic+stabilization.">Transiliac-transsacral screws for posterior pelvic stabilization.</a> Journal of Orthopaedic Trauma. 25 (6), 378-384 (2011).</li><li>Verhey, J. T., Haglin, J. M., Verhey, E. M., Hartigan, D. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Virtual,+augmented,+and+mixed+reality+applications+in+orthopedic+surgery.">Virtual, augmented, and mixed reality applications in orthopedic surgery.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 16 (2), 2067 (2020).</li></ol>

Regardless of the type of Robot, the core application of robots in orthopedics provides an advanced tool for surgeons to improve the accuracy of surgery. However, the emergence of surgical robots is not a replacement for doctors. Surgeons performing robotic surgery may or may not be in the operating room. Surgical robots generally include a computer control system, a robotic arm responsible for the operation, and a navigation system responsible for tracking. There are three categories of robot systems depending on how th...

The first robotic application utilized in orthopedic surgery was the ROBODOC system employed in 19921. Since then, robot-assisted surgical systems have rapidly developed. Robot-assisted surgery improves arthroplasty by enhancing the surgeon&#39;s ability to restore the alignment of the limb and the physiological kinematics of the joint2. In spinal surgery, the placement of pedicle screws using a robot is safe and accurate; it also reduces the surgeon&#39;s radiation exposure3. However, studies on robot-assisted surgery have been limited owing to the heterogeneity of traumatic orthopedic diseases. The existing research on robotic surgery for orthopedic trauma mainly focuses on robot-assisted sacroiliac joint screws and pubic-screw fixation of pelvic ring fractures4, cannulated screw fixation of the femoral neck5, entry point and distal locking bolts in intramedullary nailing6,7, percutaneous fracture reduction8,9, and the treatment of critically wounded patients in the military field10.
The percutaneous screw technique can be performed using 2D and 3D navigation support. The sacroiliac, anterior column, posterior column, supraacetabular, and magic screws are the most common percutaneous techniques for pelvic and acetabular factures11. The percutaneous transiliac-transsacral screw technique remains challenging for surgeons. An understanding of pelvic anatomy and X-ray fluoroscopy, accurate positioning, and long-term hand stability are required for this procedure. The teleoperated robotic system can meet these requirements well. This study utilizes a teleoperated robotic system to complete percutaneous transiliac-transsacral screw fixation for pelvic ring fractures. The details and workflow of this protocol are presented below.
Robotic system 
The Master-Slave Orthopaedic Positioning and Guidance System (MSOPGS) is mainly composed of three parts: the surgical Robot (Slave Manipulator) with seven degrees of freedom (DOF), the Master Manipulator with force feedback, and the console. The system has four operating modes: manual traction, master-slave operation, remote center of motion (ROM), and emergency. Figure 1 shows the MSOPPGS; its main components are briefly described below.
The surgical robot (see Table of Materials) is a seven DOF manipulator that is pre-certified for integration into medical products12. The Robot has force-feedback sensors that can detect changes in force. The robotic arm can be operated manually or remotely. A torque sensor is installed at the tip and mapped to the &#34;Master Manipulator,&#34; enabling real-time force feedback. The maximum load on the robotic arm is sufficient to resist soft tissue forces and reduce the fluttering of the surgical instruments. The Robot is attached to a mobile platform to acquire an operational workplace and ensure stability. The base is connected to the &#34;Master Manipulator&#34; and the operative system and can process instructions from the operative system.
The &#34;Master Manipulator&#34; is designed for healthcare industries to precisely control the Robot. This device offers seven active DOF, including high-precision force-feedback grasping capabilities. Its end effector covers the natural range of motion of the human hand. An incremental control strategy is used to achieve intuitive control of the robotic arm.
The operative system provides four methods for controlling the robotic arm: manual traction, master-slave operation mode, remote centre of motion (RCM), and emergency. The operative system links the surgeon and Robot and provides safety alarms. The manual traction mode allows the manipulator to be dragged freely within a specific working range. The Robot is automatically locked after being stopped for 5 s. In the master-slave mode, the surgeon can use the &#34;Master Manipulator&#34; to control the movement of the robotic arm. The RCM mode permits the surgical instrument to pivot around the end of the instrument. The RCM mode is best suited to reorientation on the axial fluoroscopy view of the channel, such as the radiographic teardrop sign of the supraacetabular channel and the true sacral view of the transiliac-transsacral osseous pathway. The manipulator can be used for emergency braking at any position. Figure 2 shows the workflow of the system.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>160-slice CT</td>
			<td>United Imaging Healthcare Surgical Technology Co. Ltd</td>
			<td>uCT780</td>
			<td>Acquire the prescise image and DICOM data</td>
		</tr>
		<tr>
			<td>Electric bone drill</td>
			<td>YUTONG Medical</td>
			<td>None</td>
			<td>Power system</td>
		</tr>
		<tr>
			<td>Fluoroscopic plate base</td>
			<td>None</td>
			<td>None</td>
			<td>Fix the cadaveric pelves to operating table</td>
		</tr>
		<tr>
			<td>K-wire</td>
			<td>None</td>
			<td>2.5mm</td>
			<td>Guidewire</td>
		</tr>
		<tr>
			<td>Master-Slave Orthopaedic Positioning and Guidance System</td>
			<td>United Imaging Healthcare Surgical Technology Co. Ltd</td>
			<td>None</td>
			<td>A teleoperated robotic system that positions screws for orthopaedic surgery</td>
		</tr>
		<tr>
			<td>Mimics Innovation Suite</td>
			<td>Materialise</td>
			<td>Mimics Medical 21</td>
			<td>Preoperative planning software &#160;&#160;</td>
		</tr>
		<tr>
			<td>Mobile C-arm</td>
			<td>United Imaging Healthcare Surgical Technology Co. Ltd</td>
			<td>uMC560i</td>
			<td>Low Dose CMOS Mobile C-arm</td>
		</tr>
		<tr>
			<td>Operating table&#160;</td>
			<td>KELING</td>
			<td>DL&#183;C-I</td>
			<td>Fluoroscopic surgical table</td>
		</tr>
		<tr>
			<td>Schanz pins</td>
			<td>Tianjin ZhengTian Medical Instrument Co.,Ltd.</td>
			<td>5.0mm</td>
			<td>Fix the cadaveric pelves</td>
		</tr>
		<tr>
			<td>Semi-threaded screw</td>
			<td>Tianjin ZhengTian Medical Instrument Co.,Ltd.</td>
			<td>7.3mm</td>
			<td>Transiliac-Transsacral Screw</td>
		</tr>
		<tr>
			<td>Seven DOF manipulator</td>
			<td>KUKA, Germany</td>
			<td>LBR Med 7 R800</td>
			<td>Device for performing surgical operations</td>
		</tr>
	</tbody>
</table>

a teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation technique

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. Transiliac-transsacral screws provide a longer lever arm to withstand the perpendicular vertical shear forces. However, the screw channel is so long that a minor discrepancy can lead to iatrogenic neurovascular injuries. The development of medical robots has improved the precision of surgery. The present protocol describes how to use a new teleoperated robotic system to execute transiliac-transacral screw fixation. The Robot was operated remotely to position the entry point and adjust the orientation of the sleeve. The screw positions were evaluated using postoperative computed tomography (CT). All the screws were safely implanted, as confirmed using intraoperative fluoroscopy. Postoperative CT confirmed that all the screws were in the cancellous bone. This system combines the doctor's initiative with the Robot's stability. The remote control of this procedure is possible. Robot-assisted surgery has a higher position-retention capacity compared with conventional methods. In contrast to active robotic systems, surgeons have full control over the operation. The robot system is fully compatible with operating room systems and does not require additional equipment.

A senior orthopedic surgeon completed the surgery using the procedure described. All the screws (three in S1 and two in S2) were secured. The time taken (from the first X-ray fluoroscopy to the insertion of the screw) for inserting each of the five screws was 32 min, 28 min, 26 min, 20 min, and 23 min, respectively. The fluoroscopy time for each screw was approximately 5 min. Although all the screws were in the correct place on the intraoperative fluoroscopic images, several articles have highlighted the need for postope...

Watch this Scientific Journal Video about A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique at JoVE.com

A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique

Teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation is a feasible technique. Screw channels can be implemented with high accuracy owing to the excellent freedom of movement and stability of the robotic arms.

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. ...

Transiliac-transsacral screw fixation is a challenging task in clinical practice. The teleoperated robotic system-assisted surgery offers a solution to the difficulty of transiliac-transsacral screw placement. Using this technique, surgeons can perform procedures outside the operating room, thus avoiding the danger of radiation exposure.Additionally, robot-assisted surgery has a higher position-retention capacity compared with the conventional method. This technology can be combined with 3D navigation, virtual reality, augmented reality, and mixed-reality technologies for percutaneous screw placement in the pelvic acetabulum. For efficient fixation, doctors should be skilled in placing the sacroiliac screws using freehand under fluoroscopy prior to using this technique.To begin, fix the cadaveric pelves in the supine position using a fluoroscopic plate base by inserting two Schanz pins through the femur. In the supine position, place both the posterior superior iliac spines simultaneously on the plank, and the lumbar vertebrae parallel to the floor. Using the Med CAD module of the preoperative planning software, create a cylinder of the pelves'image and define the size of the cylinder by typing in the diameter and length.Place the cylinder into the S1 or S2 vertebral body and adjust the orientation of the cylinder midline on the axial and coronal images. Check the relationship between the edge of the cylinder and the cortical bone in each image. Fix the pelvis in the supine position on the fluoroscopic operating table.Then place the robot on the ipsilateral side at 45 degrees to the operating table, with the C-arm perpendicular to the operating table on the contralateral side. Next, place the workstation of the master manipulator outside the operating room. Fix the grid position maker with adhesive tape on the ipsilateral side.Select the target area by a grid position marker on the true lateral view of the sacrum. Ensuring that the manual traction mode on the console is selected and started, drag the robotic arm to the general area of the S1 or S2 transiliac-transsacral screw entry point. Visualizing the true lateral view of the sacrum, operate the master manipulator in the master-slave operation mode, and adjust the tip of the distal sleeve to be located in the guidewire entry area.After selecting the remote center of motion, or RCM, mode, continue the C-arm fluoroscopy for the lateral sacral view. Adjust the center of the guidewire sleeve into concentric circles to be consistent with the screw channel. Lock the robotic arm and insert a 2.5 millimeter guidewire through the contralateral ileum using an electric drill.Then remove the robot in manual traction mode. Turn the C-arm to the inlet and outlet angles to check that the guidewire has broken through, or contacted the interior and posterior sacral cortex and the sacral nerve canal. Insert a 7.3-millimeter semi-threaded screw along the guidewire to the contralateral iliac cortex.Assess the screw position in the pelvic inlet, outlet, and lateral view. Import the acquired CT scan data into the pre-operative planning software in the DICOM format, to obtain the screw position in coronal, sagittal, and axial images of the pelvis. Post-operative CT reconstruction images and X-rays to evaluate the screw placement showed that no screws penetrated the cortical bone, and all the screws were completely in the cancellous bone.Sagittal CT reconstruction images of the midline site suggested that the screw is located in the S1 and did not enter the sacral canal, as seen on the reslice axial image. Also, the screw is safe, as seen on the reslice coronal CT reconstruction image. The true lateral view of the sacrum revealed that the screw is located entirely within the bone and is at a safe distance from the anterior and posterior sacral cortex and the sacral nerve canal on the inlet and outlet images.Remote controlling of this procedure is possible. The key things in this protocol are the accuracy and stability of the master-slave operation mode and RCM mode. This method is expected to become an essential part of telemedicine in the future.

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