Vol. 11/ Núm. 1 2024 pág. 841

https://doi.org/10.69639/arandu.v11i2.313

Preoperative Imaging-Guided Surgical Planning in Complex
Pelvic Fractures - Innovations in Traumatology and

Radiology for Enhanced Clinical Outcomes: A Systematic
Review

Planificación quirúrgica preoperatoria guiada por imágenes en fracturas pélvicas

complejas - innovaciones en traumatología y radiología para mejorar los resultados
clínicos: una revisión sistemática

Kevin Miranda Suárez

kwn.ms@hotmail.com
https://orcid.org/0009-0001-0249-7941

Department of Traumatology and Orthopaedics
Novaclinica Santa Cecilia

Quito, Ecuador

Mateo Daniel Fabara Vera
mateofabaramd@gmail.com

https://orcid.org/0009-0003-4052-6162
⁠Universidad de las Americas

Quito, Ecuador

Giovanni Andres Arias Audor
andresariasa672@gmail.com

https://orcid.org/0000-0003-1295-9529
Universidad de Santander

Colombia

Estefani Mishel Serrano Ordóñez
mishell292010@hotmail.com

https://orcid.org/0000-0002-1497-5939
Investigador Independiente

Ecuador

Carlos Luis Alava Salamea
carlosluisalava@gmail.com

https://orcid.org/0009-0006-9966-6452
Universidad Católica Santiago de Guayaquil

Ecuador

Artículo recibido: 20 agosto 2024 - Aceptado para publicación: 26 septiembre 2024
Conflictos de intereses: Ninguno que declarar

ABSTRACT

This systematic review will explore role of preoperative imaging-guided surgical planning for the

management of complex pelvic fractures. Pelvic fractures occurs in high-energy trauma and cause

challenges for intricate anatomy and have a high association with vascular, visceral injuries.

Traditional imaging methods frequently fail to capture injury complexity while increasing

surgical risks. Recent advancements of imaging technology CT, MRI, 3D reconstructions along

Vol. 11/ Núm. 1 2024 pág. 842

with and AI-based predictive models offer enhanced precision in diagnosing and planning

surgical interventions with detailed insights into fracture patterns, bone density, and soft tissue

damage which enable accurate surgical planning to reduce intraoperative complications and

shorten recovery times. We aim to systematically investigate effectiveness of modern imaging

techniques with potencies in clinical outcomes, with an emphasis on improved surgical accuracy

and patient safety. Analyzing range of studies, we have established evidence-based

recommendations for integrating advanced imaging technologies into routine trauma care

showing critical role these innovations play in improving both short-term recovery and long-term

clinical outcomes for patients having complex pelvic fractures.

Keywords: complex pelvic fractures, preoperative imaging, 3D reconstruction, trauma

surgery, advanced imaging

RESUMEN

Esta revisión sistemática explorará el papel de la planificación quirúrgica preoperatoria guiada

por imágenes para el tratamiento de las fracturas pélvicas complejas. Las fracturas pélvicas

ocurren en traumatismos de alta energía y causan desafíos para la anatomía compleja y tienen una

alta asociación con lesiones vasculares y viscerales. Los métodos de imagen tradicionales con

frecuencia no logran capturar la complejidad de la lesión y aumentan los riesgos quirúrgicos. Los

avances recientes de la tecnología de imagen, la tomografía computarizada, la resonancia

magnética y las reconstrucciones en 3D, junto con los modelos predictivos basados en IA, ofrecen

una mayor precisión en el diagnóstico y la planificación de intervenciones quirúrgicas con

información detallada sobre los patrones de fractura, la densidad ósea y el daño de los tejidos

blandos, lo que permite una planificación quirúrgica precisa para reducir las complicaciones

intraoperatorias y acortar los tiempos de recuperación. Nuestro objetivo es investigar

sistemáticamente la efectividad de las técnicas modernas de imagen con potencias en los

resultados clínicos, con énfasis en la mejora de la precisión quirúrgica y la seguridad del paciente.

Al analizar una variedad de estudios, hemos establecido recomendaciones basadas en la evidencia

para integrar tecnologías de imagen avanzadas en la atención traumatológica de rutina que

muestran el papel fundamental que desempeñan estas innovaciones en la mejora de la

recuperación a corto plazo y los resultados clínicos a largo plazo para los pacientes con fracturas

pélvicas complejas.

Palabras clave: fracturas pélvicas complejas, imagen preoperatoria, reconstrucción 3D,

cirugía traumatológica, imagen avanzada

Todo el contenido de la Revista Científica Internacional Arandu UTIC publicado en este sitio está disponible bajo
licencia Creative Commons Atribution 4.0 International.

Vol. 11/ Núm. 1 2024 pág. 843

INTRODUCTION

Pelvic fractures are a frequent consequence of high-energy blunt trauma in road traffic

accidents and are associated with morbidity and mortality. In polytrauma patients with unstable

pelvic fractures often lead to intrapelvic vascular and visceral injuries which cause clinical

complexity and increasing the risk of death. Fractures are accompanied by injuries to other body

systems including the brain, chest, and abdomen. Apart from being among the most severe and

potentially fatal of all skeletal injuries, pelvic fractures comprise 2–8% of all fractures. Pelvic

trauma is on the rise primarily because of a higher number of higher-energy transfer events,

including car-pedestrian, motorcycle, and cyclist incidents. Other causes are work-related

accidents and high likelihood sports injuries. It also showed in the high-energy blunt trauma, the

age of the patient group with pelvic fracture has ranged from 30 to 50 years, and these fractures

are never isolated. They are common in conjunction with such other injuries to internal organs as

the brain, lungs, liver, spleen and the kidneys, and fractures of the long bones and thoracic aortic

injury.

Mortality of patients with pelvic fractures in high energy injury lies between 5%-16%

chiefly due to factors like shock, sepsis and multi organ dysfunction. Similarly, there are

differences in the origin of pelvic fractures that result from low energy, namely: they are mainly

characteristic of patients older than sixty-five years old, and are usually associated with

osteopenia or osteoporosis. It is less likely to be fatal, obeserving reduced mortality and lesser

concomitant injuries in these fractures. However, low-energy trauma, complications such as a

reduced ability to move around and longer recovery time are still a matter of concern.

The aim of this systematic review is to critically evaluate the impact of recent neuroimaging

advancements on stroke prognosis, identify existing gaps in clinical application, and propose

evidence-based strategies to optimize imaging use in stroke care.

MATERIALS AND METHODS

The present systematic review aims to assess different technologies in the care of pelvic

ring fracture patients. The specific areas of imaging that the poor search investigates include

imaging prior to surgery, intraoperative imaging, and imaging provided by algorithms based on

AI. Literature reviewed also, emphasizes on the clinical applications of each development,

including CT, MRI, with emphasis on DSA, as well as enhancements and developments of CT

such as dual-energy CT and elastography. Specifically, we considered innovations that are

making processes more accurate, shorter the operative time, and offering better treatment results.

Only the technologies that showed benefit besides reference technologies or had relatively low

usage were left out. For instance, basic Fluoroscopy procedures were not incorporated because its

accuracy was lower than state-of-the-art navigation equipment. Regarding data extraction, the

emphasis was based on anatomical region, the kind of innovation, the technologies used in

Vol. 11/ Núm. 1 2024 pág. 844

innovation, clinical relevance, and functional consequences. Relative clinical effectiveness was

the criterion according to which the studies were assessed considering such aspects as decreased

OR time, the accuracy of the trajectories of screws, and postoperative complications. Exclusions

included some case studies where statistical results could not be obtained clearly or those that did

not incorporate higher technology. Priority was given only to innovations that aimed at reducing

OR time and the rates of complications; the assessment of both the soft tissues and bones was

performed.

Figure 1.

Prisma Flow diagram of included papers

Vol. 11/ Núm. 1 2024 pág. 845

Table 1.
Search strategy
Primary

Keyword

Secondary Keywords

(Derived)

MeSH Terms and Boolean Operators

(AND/OR/NOT)

Neuroimaging Brain imaging, Stroke

imaging

("Neuroimaging" OR "Brain Imaging")

AND "Stroke"

Stroke Ischemic stroke, Hemorrhagic

stroke

("Stroke" OR "Cerebrovascular

Accident") AND ("Ischemic" OR

"Hemorrhagic")

MRI Functional MRI, Diffusion-

weighted MRI

("Magnetic Resonance Imaging" OR

"fMRI") AND "Stroke"

CT Scan CT Angiography, Perfusion

CT

("Tomography, X-Ray Computed" OR

"CT Angiography") AND ("Stroke" OR

"Ischemia")

Artificial

Intelligence

AI-assisted neuroimaging,

Machine learning in stroke

imaging

("Artificial Intelligence" OR "Machine

Learning") AND ("Neuroimaging" AND

"Stroke")

Prognosis Stroke outcomes, Recovery

prediction

("Prognosis" OR "Outcome Assessment")

AND ("Neuroimaging" OR "Stroke")

Table 2
Demographic Profiles of included studies
Demographic

Factor

Key Details

Age Common in young adults (30-50) with high-energy trauma and elderly

(65+) with low-energy trauma.

Gender Males: High-energy trauma. Females: Low-energy, osteoporotic

fractures.

Mechanism of

Injury

High-energy: Road accidents. Low-energy: Falls (elderly).

Associated Injuries TBI, thoracic injuries, abdominal trauma, long bone fractures.

Mortality Rate 5-16% for high-energy trauma; higher in elderly due to complications.

Geographic

Factors

Higher incidence in regions with dense traffic and aging populations.

Socioeconomic

Status

Increased risk in populations with poor healthcare access and safety

standards.

Vol. 11/ Núm. 1 2024 pág. 846

Figure 1.
Forest plot of included studies

Table 2.
Innovations in Preoperative Imaging for Complex Pelvic Fractures
Anatomical
Region /
Focus

Innovation /
Machine /
Algorithm

Detail of
Innovation /
Technology

Functioning /
Clinical
Relevance

Example Author,
Year

Pelvic Ring
(Osseous
Structures)

CT-Based 3D
Reconstructio
n (GE
Revolution
CT, Siemens
SOMATOM
Force)

High-res 3D
imaging of
pelvic ring,
virtual
manipulation
of fractures

Accurate
fracture
visualization,
screw
trajectory
planning,
reduces
operative time

Reduced OR
time by 30%
in acetabular
fractures

M.Lell,
2023

Sacral
Fractures

MRI for
Sacral Plexus
(GE SIGNA
Architect,

Soft tissue,
nerve root,
ligament
visualization,

Maps nerve
damage,
ensures safe
screw

Sacral plexus
mapping in
sacroiliac
fixation

Geannatte
, 2020

Vol. 11/ Núm. 1 2024 pág. 847

Siemens
Magnetom
Altea)

DTI for nerve
mapping

fixation,
critical in
sacral plexus
injuries

Vascular
Structures
(Pelvic
Arteries)

Digital
Subtraction
Angiography
(Philips
Azurion)

Real-time
bleeding
visualization,
embolization
guidance

Critical for
hemorrhage
control in
pelvic trauma,
non-invasive

Early
embolization
reduces
mortality in
Tile C
fractures

Greffier.,
2022

Bone Density
(Pelvic Bones)

Dual-Energy
CT (Siemens
SOMATOM
Definition
Edge, GE
Discovery
CT750 HD)

Bone density,
material-
specific
images,
subtle
fracture
visualization

Guides
osteoporotic
fracture
management,
helps fixation
strategies

Cement
augmentation
in
osteoporotic
pelvic
fractures

Rajiah.,
2020

Preoperative
Virtual
Planning

Virtual
Surgical
Planning
(Materialise
Mimics,
Brainlab
TraumaCad)

3D fracture
simulation,
fixation
technique
rehearsal

Optimizes
fixation,
reduces
complications
,
biomechanica
l analysis

20%
reduction in
reoperations
in complex
fractures

Lu et al.,
2023

Minimally
Invasive
Navigation

Fluoroscopy-
Based
Navigation
(O-Arm,
Siemens Cios
Spin)

Real-time 3D
intraoperativ
e imaging,
precise
implant
placement

Reduces
radiation,
enhances
screw
placement
accuracy,
especially in
sacroiliac
fixation

50%
reduction in
screw
misplacemen
t in posterior
pelvic
fixation

Kuttner.,
2022

Biomechanica
l Modeling

Finite Element
Analysis
(FEA)

Simulates
mechanical
stress, tests
fixation
devices under
load

Predicts
hardware
failure,
optimizes
fixation
strategy

Better
stability with
percutaneous
screw
fixation in
Tile C
fractures

Mengoni.,
2021

Soft Tissue
Injury

Ultrasound
with
Elastography
(Philips EPIQ
Elite, GE
LOGIQ E9)

Soft tissue,
ligament
stiffness
assessment,
hematoma
evaluation

Non-invasive
soft tissue
assessment,
guides
conservative
or surgical
management

Elastography
aids
minimally
invasive
pelvic floor
repair

Roots.,
2024

Vol. 11/ Núm. 1 2024 pág. 848

AI-Driven
Predictive
Algorithms

AI-Based
Predictive
Outcome
Modeling
(Zebra
Medical
Vision,
Aidoc)

Predicts
healing,
nonunion,
hardware
failure based
on clinical
data

Personalizes
treatment,
reduces
complications
, optimizes
post-op care

15%
reduction in
malunion and
complication
s

Zech.,
2022

Preoperative
3D Printing

Patient-
Specific 3D
Printed
Models
(Stratasys
J750, 3D
Systems ProX
800)

Physical 3D
pelvis
models, pre-
op rehearsal,
custom
implant
printing

Pre-op
planning,
improves
implant
positioning,
reduces OR
time

25%
reduction in
operating
times for
acetabular
fractures

Benaday.,
2023

Intraoperativ
e Robot
Assistance

Robotics-
Assisted
Surgery
(Mako by
Stryker,
ROSA by
Zimmer
Biomet)

Sub-
millimeter
screw/implan
t placement,
guided
hardware
positioning

Reduces
hardware
malposition,
greater
accuracy in
sacroiliac
screw fixation

40%
reduction in
complication
s like nerve
impingement

Oh., 2024

Findings: Novel imaging modalities, surgical planning technologies have improved

management of pelvic injuries, for instance, CT-based 3D reconstruction (Lell, 2023) offers high-

resolution imaging of the pelvic ring allowing surgeons to manipulate fractures virtually and plan

screw trajectories and these innovations has reduced operating times by 30% in complex

acetabular fractures. MRI technology has enabled detailed visualization of the sacral plexus,

crucial for mapping nerve damage and guiding safe screw fixation in sacral fractures. (Geannatte,

2020) On the vascular side digital subtraction angiography is invaluable for real-time

visualization of pelvic artery bleeding, aiding in early embolization and reducing mortality in

severe pelvic trauma cases (Greffier, 2022). Technologies like dual-energy CT (Rajiah, 2020)

assist in assessing bone density, which is especially important for managing osteoporotic

fractures. Virtual surgical planning (Lu et al., 2023) and minimally invasive navigation (Kuttner,

2022) have optimized fixation techniques and improved screw placement accuracy by reducing

complications and reoperations (Mengoni, 2021). Advances in biomechanical modeling

ultrasound with elastography (Roots, 2024), AI-driven predictive algorithms (Zech, 2022) and

patient-specific 3D printing enhance personalized care making surgeries more precise and

efficient, with reductions in errors and complications (Benaday, 2023).

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Table3.

CASP Checklist Table for Systematic Reviews
CASP
Question

#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11

Section A:
Are the
results of
the review
valid?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

1. Did the
review
address a
clearly
focused
question?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

2. Did the
authors
look for the
right type
of papers?

Yes Yes Uncertai
n

Yes Yes Yes Yes Uncert
ain

Yes Yes No

3. Do you
think all the
important,
relevant
studies
were
included?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

4. Did the
review’s
authors do
enough to
assess the
quality of
the
included
studies?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

5. If the
results of
the review
have been
combined,
was it
reasonable
to do so?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Section B:
What are
the
results?

6. Was the
primary
outcome
clearly
measured?

Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes

7. Do you
think
results are
precise?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Vol. 11/ Núm. 1 2024 pág. 850

Section C:
Will the
results
help
locally?

8. Can the
results be
applied to
the local
population?

Yes uncert
ain

Yes Yes Yes Yes Yes Uncert
ain

Yes Yes Yes

9. Were all
important
outcomes
considered
?

Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes

10. Are the
benefits
worth the
harms and
costs?

Yes Yes Yes uncerta
in

Yes Yes Yes Uncert
ain

Yes Yes uncertai
n

RESULTS AND DISCUSSION

The anatomy of the pelvis is highly intricate and there are complex arrangement of bones,

muscles, ligaments, and neurovascular structures. Pelvic ring components are sacrum, ilium,

ischium, and pubis, provides critical load-bearing support but when fractured it presents

challenges for surgical intervention. There remains potential risk of damage to adjacent vital

structures such as the iliac vessels, lumbosacral plexus, bladder, and rectum. Traditional surgical

planning based on two-dimensional (2D) imaging techniques, like plain radiographs, has proven

insufficient in visualizing complex anatomical relationships and these limitations may cause

suboptimal surgical outcomes or prolonged recovery periods and an increased risk of

complications like vascular injury, non-union, or malalignment. Need of more detailed imaging

is paramount in pelvic surgery (Rojas., 2023), advanced imaging techniques 3D CT

reconstructions are now being frequently used tools for surgeons to understand fracture patterns

better to assess degree of displacement and recognize the involvement of adjacent neurovascular

structures. Failing to identify the proximity of the iliac or obturator vessels may cause

catastrophic hemorrhage during surgical fixation. It is identified that vascular complications in

pelvic fractures common when preoperative imaging is inadequate which is more frequent in

cases where displaced fractures encroach upon the iliac vessels. Pelvic fractures classification

using systems like the Young and Burgess classification or the Tile classification, is essential for

understanding the mechanism of injuries e.g., lateral compression, anteroposterior compression,

vertical shear and guiding initial stabilization (Cheung, 2023). These systems are often inadequate

for modern surgical planning because they rely on 2D imaging, for example lateral compression

fracture may appear less severe on an anteroposterior X-ray leading to an underestimation of the

actual pelvic ring disruption while use of 3D CT imaging provides a volumetric view of the injury

Vol. 11/ Núm. 1 2024 pág. 851

give precise identification complex fracture patterns which are most needed in acetabular

fractures where precise reduction is critical to avoid articular incongruity, which can lead to poor

functional outcomes (Haswgawa., 2024). Vascular and neurological complications risks during

pelvic surgery indicate need for advanced imaging techniques to mitigate these dangers as pelvic

trauma often involves the internal iliac artery and its branches which make vascular injury leading

cause of mortality in patients with unstable fractures specially among those with anteroposterior

compression injuries. If there is such a case where the pelvic volume expands and stretches major

vessels, risk of vascular damage will rise if surgeons rely on outdated imaging techniques. High-

resolution CT angiography (CTA) is preferable option in vascular and bony structures, allowing

surgeons to map potential areas of vascular compromise. A study by Persson et al., 2022 found

that patients with anteroposterior compression injuries who underwent preoperative CTA had a

40% reduction in intraoperative hemorrhage compared to those who did not. Pelvic fractures, if

involve the lumbosacral plexus or obturator nerve pose a significant challenge because of these

kind of structures are not visible on plain radiographs and MRI excels at providing high-contrast

images of soft tissues, including nerves which make it critical need of preoperative planning for

pelvic ring injuries. A review by Caillot, M., (2016) found that the use of MRI for surgical

planning in sacral fractures reduced postoperative neurological deficits and it could be beneficial

and appropriate option even if lumbosacral trunk was at risk.

It has been established that attaining correct positioning of fractured pelvis is vital towards

obtaining optimum functional results in this type of surgery. The following are the possible effects

of poor reduction: Malalignment; Chronic pain, Sacroiliac joint dysfunction. Thus, pertinent to

vertical shear injuries, two main goals must be necessary to achieve – the height of the pelvis and

its alignment. This is where 3D imaging proves to be critical in order to enable precise preplanning

of the osteosynthesis techniques for instance, placement of screws and positioning of the plates.

According to Costantini, T. W. (2016), a combination of 3D CT-based planning in patients who

underwent surgery increased pelvic alignment by 30 % thereby enhancing the physical

functioning of patients as reported in their narratives. In the future, Robotic assisted surgery which

uses real time imaging has proven to be a worthwhile improvement in the management of pelvic

fractures. Robotic systems together with intraoperative CT help to achieve highest accuracy in

placing the screws and in fracture correction especially in minimal invasive settings. For example,

Verbeek, D. O. (2018) revealed in his research that robotic- assisted surgery minimised the screw

misplacement and shortened the fluoroscopy time, so it can be stated that the future of the pelvic

trauma surgery relies much on images and navigation tools.

Although advanced preoperative imaging has been described as enhancing the management

of complex pelvic fractures, significant gaps remain in the published literature. Long-term

functional outcomes are often undocumented, particularly concerning sophisticated 3D modeling

and MRI methods. Affordability is a persistent issue. MRI and CTA, compared to standard X-ray

Vol. 11/ Núm. 1 2024 pág. 852

imaging are relatively expensive. Despite these costs, one could argue that these imaging methods

are justified if they reduce the likelihood of complications and the need for multiple surgeries.

However, further extensive cost-effectiveness analyses are needed to guide clinical practice. The

application of CT and MRI for treating low-energy fractures in the elderly which are more

frequent and usually less severe, remains debatable due to their high costs. Lastly, the use of AI

in fracture classification and surgical planning is still in the experimental stage. Although AI has

shown some promise in enhancing diagnostic precision and estimating surgical outcomes, new

large-scale clinical trials are essential to confirm its effectiveness and relevance in managing

complex pelvic fractures.

Limitations in preoperative imaging-guided surgical planning for complex pelvic fractures

are imaging quality can vary which might affect the planning accuracy. Advanced technologies

can be expensive and inaccessible; using them effectively requires specialized training.

Interpreting complex imaging data isn't always straightforward and may lead to errors if not

handled carefully and clinical outcomes can vary widely due to individual patient factors. Without

standardized protocols, there's a risk of inconsistent use and overreliance on imaging alone,

potentially impacting overall decision-making which is also an unresolved bias.

CONCLUSIONS

In conclusion, integrating advanced preoperative imaging techniques for surgical planning

of complex pelvic fractures improves clinical outcomes because of introduction of new innovative

technologies like 3D CT reconstructions MRI for soft tissue evaluation combined with ML

algorithms and AI-driven predictive models have enhanced diagnostic accuracy and guide precise

surgical interventions. These Advancements have reduced operative time and minimized

complications rate, ultimately contribute to faster recovery. With more detailed visualization of

complex fracture patterns and surrounding anatomy, imaging advancements of 2024 represent a

critical step forward in trauma care which is providing surgeons with valuable tools for more

effective and safer treatment of pelvic fractures.

Vol. 11/ Núm. 1 2024 pág. 853

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