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 traumatologÃa y radiologÃa para mejorar los resultados
clÃnicos: una revisión sistemática
Kevin Miranda Suárez
kwn.ms@hotmail.com
https://orcid.org/0000-0002-9357-4067
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
ArtÃculo 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 energÃa y causan desafÃos para la anatomÃa 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 tecnologÃa de imagen, la tomografÃa 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 clÃnicos, 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 tecnologÃas 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 clÃnicos a largo plazo para los pacientes con fracturas
pélvicas complejas.
Palabras clave: fracturas pélvicas complejas, imagen preoperatoria, reconstrucción 3D,
cirugÃa traumatológica, imagen avanzada
Todo el contenido de la Revista CientÃfica Internacional Arandu UTIC publicado en este sitio está disponible bajo
licencia Creative Commons Atribution 4.0 International.
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 energÃa y causan desafÃos para la anatomÃa 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 tecnologÃa de imagen, la tomografÃa 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 clÃnicos, 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 tecnologÃas 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 clÃnicos a largo plazo para los pacientes con fracturas
pélvicas complejas.
Palabras clave: fracturas pélvicas complejas, imagen preoperatoria, reconstrucción 3D,
cirugÃa traumatológica, imagen avanzada
Todo el contenido de la Revista CientÃfica 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
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
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.
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
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
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).
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).
Vol. 11/ Núm. 1 2024 pág. 849
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
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
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
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.
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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Benady, A., Meyer, S. J., Golden, E., Dadia, S., & Levy, G. K. (2023). Patient-specific Ti-6Al-
4V lattice implants for critical-sized load-bearing bone defects reconstruction. Materials &
Design, 226, 111605.
Cheung, J., Wong, C. K. K., Yang, M. L. C., Wong, O. F., Cheung, M., Lui, C. T., & Tsui, K. L.
(2021). Young–Burgess classification: inter-observer and inter-method agreement between
pelvic radiograph and computed tomography in emergency polytrauma management. Hong
Kong Journal of Emergency Medicine, 28(3), 143-151.
Costantini, T. W., Coimbra, R., Holcomb, J. B., Podbielski, J. M., Catalano, R., Blackburn, A., ...
& AAST Pelvic Fracture Study Group. (2016). Current management of hemorrhage from
severe pelvic fractures: Results of an American Association for the Surgery of Trauma
multi-institutional trial. Journal of Trauma and Acute Care Surgery, 80(5), 717-725.
Geannette, C., Lee, S. C., & Sneag, D. B. (2020). Etiology of lumbosacral radiculoplexopathy:
sacral insufficiency fracture on magnetic resonance imaging. HSS Journal®, 16(2), 126-
129.
Greffier, J., Dabli, D., Kammoun, T., Goupil, J., Berny, L., Touimi Benjelloun, G., ... & Frandon,
J. (2022). Retrospective Analysis of Doses Delivered during Embolization Procedures over
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Hasegawa, I. G., & Gary, J. L. (2024). Intraoperative imaging challenges during pelvic ring
disruptions and acetabular fracture surgery. Orthopedic Clinics, 55(1), 73-87.
Kuttner, H., Benninger, E., Fretz, V., & Meier, C. (2022). Fluoroscopy-guided vs. navigated
iliosacral screw placement with intraoperative 3D scan or postoperative CT control: Impact
of the clinical workflow on patients’ radiation exposure: Radiation exposure of different
workflows for iliosacral screw placement. Injury, 53(11), 3764-3768.
Lell, M., & Kachelrieß, M. (2023). Computed tomography 2.0: new detector technology, AI, and
other developments. Investigative Radiology, 58(8), 587-601.
Lu, S., Yang, Y., Li, S., Zhang, L., Shi, B., Zhang, D., ... & Hu, Y. (2023). Preoperative virtual
reduction planning algorithm of fractured pelvis based on adaptive templates. IEEE
Transactions on Biomedical Engineering, 70(10), 2943-2954.
Mengoni, M. (2021). Biomechanical modelling of the facet joints: a review of methods and
validation processes in finite element analysis. Biomechanics and modeling in
mechanobiology, 20(2), 389-401.
Oh, S., Yi, J., Song, A. Y., Jee, J., Bae, N., & Shin, J. H. (2024). Intraoperative Complications
and Perioperative and Surgical Outcomes of Single-Port Robotics-Assisted
Sacrocolpopexy. International Urogynecology Journal, 1-6.
REFERENCES
Benady, A., Meyer, S. J., Golden, E., Dadia, S., & Levy, G. K. (2023). Patient-specific Ti-6Al-
4V lattice implants for critical-sized load-bearing bone defects reconstruction. Materials &
Design, 226, 111605.
Cheung, J., Wong, C. K. K., Yang, M. L. C., Wong, O. F., Cheung, M., Lui, C. T., & Tsui, K. L.
(2021). Young–Burgess classification: inter-observer and inter-method agreement between
pelvic radiograph and computed tomography in emergency polytrauma management. Hong
Kong Journal of Emergency Medicine, 28(3), 143-151.
Costantini, T. W., Coimbra, R., Holcomb, J. B., Podbielski, J. M., Catalano, R., Blackburn, A., ...
& AAST Pelvic Fracture Study Group. (2016). Current management of hemorrhage from
severe pelvic fractures: Results of an American Association for the Surgery of Trauma
multi-institutional trial. Journal of Trauma and Acute Care Surgery, 80(5), 717-725.
Geannette, C., Lee, S. C., & Sneag, D. B. (2020). Etiology of lumbosacral radiculoplexopathy:
sacral insufficiency fracture on magnetic resonance imaging. HSS Journal®, 16(2), 126-
129.
Greffier, J., Dabli, D., Kammoun, T., Goupil, J., Berny, L., Touimi Benjelloun, G., ... & Frandon,
J. (2022). Retrospective Analysis of Doses Delivered during Embolization Procedures over
the Last 10 Years. Journal of Personalized Medicine, 12(10), 1701.
Hasegawa, I. G., & Gary, J. L. (2024). Intraoperative imaging challenges during pelvic ring
disruptions and acetabular fracture surgery. Orthopedic Clinics, 55(1), 73-87.
Kuttner, H., Benninger, E., Fretz, V., & Meier, C. (2022). Fluoroscopy-guided vs. navigated
iliosacral screw placement with intraoperative 3D scan or postoperative CT control: Impact
of the clinical workflow on patients’ radiation exposure: Radiation exposure of different
workflows for iliosacral screw placement. Injury, 53(11), 3764-3768.
Lell, M., & Kachelrieß, M. (2023). Computed tomography 2.0: new detector technology, AI, and
other developments. Investigative Radiology, 58(8), 587-601.
Lu, S., Yang, Y., Li, S., Zhang, L., Shi, B., Zhang, D., ... & Hu, Y. (2023). Preoperative virtual
reduction planning algorithm of fractured pelvis based on adaptive templates. IEEE
Transactions on Biomedical Engineering, 70(10), 2943-2954.
Mengoni, M. (2021). Biomechanical modelling of the facet joints: a review of methods and
validation processes in finite element analysis. Biomechanics and modeling in
mechanobiology, 20(2), 389-401.
Oh, S., Yi, J., Song, A. Y., Jee, J., Bae, N., & Shin, J. H. (2024). Intraoperative Complications
and Perioperative and Surgical Outcomes of Single-Port Robotics-Assisted
Sacrocolpopexy. International Urogynecology Journal, 1-6.
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Persson, P., Chong, P., Steele, C. W., & Quinn, M. (2022). Prevention and management of
complications in pelvic exenteration. European Journal of Surgical Oncology, 48(11),
2277-2283.
Rajiah, P., Parakh, A., Kay, F., Baruah, D., Kambadakone, A. R., & Leng, S. (2020). Update on
multienergy CT: physics, principles, and applications. Radiographics, 40(5), 1284-1308.
Rojas, J., Jiménez, A. M., González-Rico, H. A., Salas, M., Fierro, G., & González, J. C. (2023).
Preoperative planning in reverse shoulder arthroplasty: plain radiographs vs. computed
tomography scan vs. navigation vs. augmented reality. Annals of Joint, 8.
Roots, J. (2024). Shear Wave Elastography to assess the change in stiffness of muscles in the
acute stage post-stroke (Doctoral dissertation, Queensland University of Technology).
Verbeek, D. O., Ponsen, K. J., Fiocco, M., Amodio, S., Leenen, L. P., & Goslings, J. C. (2018).
Pelvic fractures in the Netherlands: Epidemiology, characteristics, and risk factors for in-
hospital mortality in the older and younger population. European Journal of Orthopaedic
Surgery & Traumatology, 28, 197-205.
William, A. (2022). Radiologic guidance in surgical decision-making. Cosmic Journal of Biology,
1(1), 200-227.
Zech, J. R., Santomartino, S. M., & Yi, P. H. (2022). Artificial intelligence (AI) for fracture
diagnosis: an overview of current products and considerations for clinical adoption, from
the AJR special series on AI applications. American Journal of Roentgenology, 219(6),
869-878.
Persson, P., Chong, P., Steele, C. W., & Quinn, M. (2022). Prevention and management of
complications in pelvic exenteration. European Journal of Surgical Oncology, 48(11),
2277-2283.
Rajiah, P., Parakh, A., Kay, F., Baruah, D., Kambadakone, A. R., & Leng, S. (2020). Update on
multienergy CT: physics, principles, and applications. Radiographics, 40(5), 1284-1308.
Rojas, J., Jiménez, A. M., González-Rico, H. A., Salas, M., Fierro, G., & González, J. C. (2023).
Preoperative planning in reverse shoulder arthroplasty: plain radiographs vs. computed
tomography scan vs. navigation vs. augmented reality. Annals of Joint, 8.
Roots, J. (2024). Shear Wave Elastography to assess the change in stiffness of muscles in the
acute stage post-stroke (Doctoral dissertation, Queensland University of Technology).
Verbeek, D. O., Ponsen, K. J., Fiocco, M., Amodio, S., Leenen, L. P., & Goslings, J. C. (2018).
Pelvic fractures in the Netherlands: Epidemiology, characteristics, and risk factors for in-
hospital mortality in the older and younger population. European Journal of Orthopaedic
Surgery & Traumatology, 28, 197-205.
William, A. (2022). Radiologic guidance in surgical decision-making. Cosmic Journal of Biology,
1(1), 200-227.
Zech, J. R., Santomartino, S. M., & Yi, P. H. (2022). Artificial intelligence (AI) for fracture
diagnosis: an overview of current products and considerations for clinical adoption, from
the AJR special series on AI applications. American Journal of Roentgenology, 219(6),
869-878.