Sacroiliac joint fusion navigation: how accurate is pin placement?

Shea M. ComadollDepartments of Orthopedic Surgery and

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Jason J. HaselhuhnDepartments of Orthopedic Surgery and

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Jonathan N. SembranoDepartments of Orthopedic Surgery and

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Christian M. OgilvieDepartments of Orthopedic Surgery and

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Edward Y. ChengDepartments of Orthopedic Surgery and

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Kristen E. JonesDepartments of Orthopedic Surgery and
Neurosurgery, University of Minnesota, Minneapolis, Minnesota

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Christopher T. MartinDepartments of Orthopedic Surgery and

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David W. Polly Jr.Departments of Orthopedic Surgery and
Neurosurgery, University of Minnesota, Minneapolis, Minnesota

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OBJECTIVE

Sacroiliac joint (SIJ) fusion utilizing intraoperative navigation requires a standard reference frame, which is often placed using a percutaneous pin. Proper placement ensures the correct positioning of SIJ fusion implants. There is currently no grading scheme for evaluation of pin placement into the pelvis. The purpose of this study was to evaluate the occurrence of ideal percutaneous pin placement into the posterior ilium during navigated SIJ fusion.

METHODS

After IRB approval was obtained, electronic medical records and intraoperative computed tomography images of patients who underwent navigated SIJ fusion by the senior author between October 2013 and January 2020 were reviewed. A pin placement grading scheme and the definition of "ideal" placement were developed by the authors and deemed acceptable by fellow attending surgeons. Six attending surgeons completed two rounds of pin placement grading, and statistical analysis was conducted.

RESULTS

Of 90 eligible patients, 73.3% had ideal pin placement, 17.8% medial/lateral breach, and 8.9% complete miss. Male patients were 3.7 times more likely to have ideal placement than females (p < 0.05). There was no relationship between BMI, SIJ fusion laterality, or pin placement laterality and ideal placement. Interobserver reliability was 0.72 and 0.70 in the first and second rounds, respectively, and defined as "substantial agreement." Intraobserver reliability ranged from 0.74 (substantial agreement) to 0.92 (almost perfect agreement).

CONCLUSIONS

Nonideal pin placement occurred in 26.7% of cases, but a true "miss" into the sacrum was rare. Ideal pin placement was more likely in males and was not associated with BMI, SIJ fusion laterality, or pin placement laterality. The grading scheme developed has high intraobserver and interobserver reliability, indicating that it is reproducible and can be used for future studies. When placing percutaneous pins, surgeons must be aware of factors that can decrease placement accuracy, regardless of location.

ABBREVIATIONS

BMI = body mass index; CT = computed tomography; DRF = dynamic reference frame; EMR = electronic medical record; PSIS = posterior superior iliac spine; SIJ = sacroiliac joint.

OBJECTIVE

Sacroiliac joint (SIJ) fusion utilizing intraoperative navigation requires a standard reference frame, which is often placed using a percutaneous pin. Proper placement ensures the correct positioning of SIJ fusion implants. There is currently no grading scheme for evaluation of pin placement into the pelvis. The purpose of this study was to evaluate the occurrence of ideal percutaneous pin placement into the posterior ilium during navigated SIJ fusion.

METHODS

After IRB approval was obtained, electronic medical records and intraoperative computed tomography images of patients who underwent navigated SIJ fusion by the senior author between October 2013 and January 2020 were reviewed. A pin placement grading scheme and the definition of "ideal" placement were developed by the authors and deemed acceptable by fellow attending surgeons. Six attending surgeons completed two rounds of pin placement grading, and statistical analysis was conducted.

RESULTS

Of 90 eligible patients, 73.3% had ideal pin placement, 17.8% medial/lateral breach, and 8.9% complete miss. Male patients were 3.7 times more likely to have ideal placement than females (p < 0.05). There was no relationship between BMI, SIJ fusion laterality, or pin placement laterality and ideal placement. Interobserver reliability was 0.72 and 0.70 in the first and second rounds, respectively, and defined as "substantial agreement." Intraobserver reliability ranged from 0.74 (substantial agreement) to 0.92 (almost perfect agreement).

CONCLUSIONS

Nonideal pin placement occurred in 26.7% of cases, but a true "miss" into the sacrum was rare. Ideal pin placement was more likely in males and was not associated with BMI, SIJ fusion laterality, or pin placement laterality. The grading scheme developed has high intraobserver and interobserver reliability, indicating that it is reproducible and can be used for future studies. When placing percutaneous pins, surgeons must be aware of factors that can decrease placement accuracy, regardless of location.

Percutaneous pin placement is used in a variety of orthopedic surgery settings. These include, but are not limited to, external fixator application, fracture fixation, and establishment of reference frames for computer-based navigation systems. Pin placement is typically uncomplicated; however, patient, surgeon, and anatomical site–specific factors may create additional challenges. Patients with osteoporosis, those with a history of prior surgical procedures at the pin site, and larger patients with more soft tissue may complicate placement. Surgeons with limited experience using percutaneous pins may not be familiar with placement techniques. Oblique bony surfaces may present with more difficulty and increase the likelihood of skiving compared with insertion of a pin into a perpendicular surface.

The use of intraoperative navigation systems has increased in a variety of orthopedic subspecialties. Pin placement has been frequently used to establish reference frames for these systems. For sacroiliac joint (SIJ) fusion utilizing intraoperative navigation, a standard reference frame is often placed with a percutaneous pin. Ideal pin placement is in the contralateral iliac wing with entry along the posterior superior iliac spine (PSIS), which is an oblique surface.1 The combination of ilium obliquity, tough cortical bone in the iliac wing, and the convex shape of the entry point results in a high risk of pin skiving and a more medial or lateral starting point. Preoperative imaging is typically used to determine the pin placement site, and intraoperative fluoroscopy is used to aid with insertion.

Utilizing a reference frame allows for computed tomography (CT)–guided navigation when placing SIJ screws. Additionally, navigated fixation of the SIJ allows for minimally invasive techniques to be used, which have lower risk of morbidity than open techniques.2 It has been suggested that CT guidance allows for more accurate screw placement than traditional fluoroscopic techniques.2,3 However, a prospective multicenter study found that 2.5% of screws were not optimally placed even with this improved precision.3

The accuracy of navigated surgery is highly reliant on reference frames.4 The reference frame for SIJ fusion is often placed through a stab incision into the contralateral posterior ilium or sacrum.2 Parameters that have been shown to influence the accuracy of sacroiliac implant placement include accurate reference frame registration, the insertion angle, and surgeon experience.2,5,6 Similarly, the anatomy of the bony target, surrounding soft tissues, large angle to the bone surface at the starting point, and a trajectory along the long axis of a cortical surface can increase the risk of skiving during screw insertion.7

The focus of this study was to determine the accuracy of pin placement for reference frame establishment. To our knowledge, there is no grading scheme for evaluation of percutaneous pin placement into the pelvis. Our study examined both the accuracy of pin placement and patient-specific factors that may increase the risk of inaccurate pin placement in these patients. We hypothesized that male sex and higher body mass index (BMI) would be associated with a higher incidence of nonideal pin placement due to the obliquity of the male ilia and increased soft tissue that can make placement difficult, respectively.

Methods

After institutional review board approval was obtained, the electronic medical records (EMRs) and intraoperative CT imaging studies of patients who underwent navigated SIJ fusion for sacroiliitis by D.W.P. between October 2013 and January 2020 were reviewed. Intraoperative CT scan slices were reviewed and compiled by S.M.C. and reviewed by D.W.P. These images were assessed prior to survey administration to determine whether the pin could be visualized along its course, as well as its relationships to the PSIS and medial and lateral cortices of the ilium. Patients were excluded if they did not undergo SIJ fusion, if the pin for the reference frame could not be adequately visualized on the intraoperative CT or selected images, or if they had a pin that had been intentionally placed in an area other than the posterior ilium.

The SIJ fusion procedure has been done in a similar fashion by D.W.P. since 2010. The patient is placed prone on a 4-poster frame on a carbon fiber table (Trios, Mizuho). Intraoperative cone-beam CT (O-arm, Medtronic) is brought in from the contralateral side. It is positioned such that the maximum caudal robotic position provides the desired imaging field of view of the pelvis. The base remains stationary, and the robotic function is used to move the base cephalad to allow the surgeon optimal working room. The surgeon palpates the contralateral PSIS and places a Kelly clamp in the presumed position. This is then confirmed with fluoroscopy. Local anesthetic is infiltrated and the skin incised. The Kelly clamp is then used to palpate the posterior ilium. The percutaneous reference pin is then impacted into the posterior ilium, attempting to be in line with the iliac wing. Stability of the pin is tested manually with a gentle toggle. The pin is accepted if it is rigid; if not, it is repositioned. The navigation spin is then done, and minimally invasive SIJ fusion is performed. The field of view includes the percutaneous pin and provided the basis for this study. D.W.P. has performed roughly 300 primary procedures in this fashion.

A placement grading scheme was developed initially and then tested (Fig. 1). The definition of "ideal" pin placement was developed by D.W.P. and was defined as a pin that entered the pelvis at the PSIS and remained completely within the posterior ilium with no medial or lateral cortical breach throughout its course. Because all patients in this study underwent surgery by D.W.P., the goal of each surgery was ideal pin positioning.

FIG. 1.
FIG. 1.

Grading scheme for pin placement.

Patient EMRs were reviewed to gather demographic and surgical information, including patient age, sex, BMI, SIJ fusion laterality, and pin placement laterality. For the purposes of this retrospective review study, no clinical follow-up was collected.

Patient intraoperative images were compiled into a Qualtrics survey, which was then distributed to six attending surgeons at two time points 3 months apart. Four attending surgeons completed both rounds of grading, and two attending surgeons completed one round of grading.

Statistical Analysis

Statistical analysis was performed using Stata Statistical Software Release 17 (StataCorp LLC). Descriptive statistics were calculated for patient age, patient BMI, SIJ fusion laterality, pin placement laterality, and pin placement grade. Univariate tests of association, including the Fisher’s exact test, chi-square, and 2-sample t-test, were completed for ideal pin placement versus sex, BMI, SIJ fusion laterality, and pin placement laterality. Univariate and multivariate logistic regression analyses of ideal pin placement with sex, BMI, SIJ fusion laterality, and pin placement laterality were used to confirm the prior univariate tests and determine odds ratios. Cohen’s kappa was calculated for interobserver and intraobserver reliability between the two rounds of grading. Agreement based on kappa was described per Landis and Koch: < 0, poor; 0–0.2, slight; 0.2–0.4, fair; 0.4–0.6, moderate; 0.6–0.8, substantial; and 0.8–1, almost perfect.8

Results

Ninety patients (71% female) were included in the final study. The mean ± SD (range) BMI was 28.8 ± 5.3 (19.9–42.7). Fifty (55.56%) patients had pins placed into their right ilium. SIJ fusion laterality included 49 (54.4%) left, 39 (43.3%) right, and 2 (2.2%) bilateral.

Ideal placement occurred in 66 (73.3%) patients (Fig. 2A), 16 (17.8%) had a medial or lateral breach not contained completely in the ilium (Fig. 2B), and 8 (8.9%) had complete misses with sacral pin placement (Fig. 2C). Univariate logistic regression demonstrated no relationship between ideal placement and BMI (p = 0.692), SIJ fusion laterality (p = 0.503), or pin placement laterality (p = 0.424). Male patients were 3.7 times more likely to have ideal placement than females (p < 0.05). Multivariate logistic regression also demonstrated no relationship between ideal placement and BMI (p = 0.982), SIJ fusion laterality (p = 0.806), or pin placement laterality (p = 0.605). Males were 4 times more likely to have ideal placement than females (p < 0.05).

FIG. 2.
FIG. 2.

Pin placement examples. A: Ideal placement. B: Medial breach. C: Complete miss. D: Poor interobserver reliability.

The survey responses to validate the grading scheme revealed mean ± SD (range) interobserver reliabilities of 0.72 ± 0.09 (0.56–0.82) and 0.70 ± 0.06 (0.58–0.77) in the first and second rounds, respectively, which were defined as "substantial agreement." The measured intraobserver reliability ranged from 0.74 (substantial agreement) to 0.92 (almost perfect agreement) (SD ± 0.08).

Discussion

This study sought to examine the accuracy of pin placement and establish a grading scheme for pin placement. In the hands of an experienced surgeon, ideal placement occurred 73.3% of the time. Additionally, the developed grading scheme demonstrated reproducibility and reliability in terms of both intraobserver and interobserver reliability.

Establishment of reference frames is key to using intraoperative navigation in minimally invasive SIJ fusion surgery. As with placement of any percutaneous pin or hardware, it is important to have accurate placement. In this study, ideal placement occurred in 73.3% of cases. A prior study by Holste et al. evaluated the placement of a dynamic reference frame (DRF) in 72 navigated lumbosacral spine operations and demonstrated that the majority of pins (77.8%) were placed correctly into the PSIS.9 This is comparable to our results.

Male sex was the only patient factor significantly associated with ideal placement. A retrospective review of 100 male and 100 female pelvic CT scans by Wang et al. found that the average iliac outlet angle was greater in males (133.9°) than females (130.7°) (p = 0.01).10 The iliac outlet angle was defined as the angle formed by the iliac wing and the superior pubic ramus, corresponding to the flare of the iliac wing. Males also had significantly larger diameters of the supra-acetabular crest, anterior column, posterior column, and gluteal pillar osseous corridor than females (all p < 0.001). These results suggest that males had a larger average target for posterior ilium pin placement, resulting in higher ideal placement rates than females.

Patients with higher BMI were expected to have an increased rate/risk of nonideal placement due to increased soft tissue that could make placement more difficult; however, no association was demonstrated. This may have been due to the mean ± SD (range) BMI of this cohort, 28.8 ± 5.3 (19.9–42.7), thereby classifying them as overweight. Additionally, if a patient has more abdominal adiposity than adiposity in their gluteal regions, pin placement may not be affected. The layer of adiposity over the pin site was not analyzed as a part of this study, but this could be useful for future studies. Laterality was not associated with a difference in accuracy. It can be speculated that this was due to the prone position of the patients, which allowed equal access to the posterior ilium.

To our knowledge, this is the first paper to assess and develop a grading scheme for percutaneous pin placement into the pelvis. The grading scheme developed and utilized in this study had high intraobserver and interobserver reliability, as demonstrated by the pairwise Cohen’s kappa coefficient. The high reliability of our grading scheme indicates that this method of grading is highly reproducible. This grading scheme could be used or adapted for future studies analyzing percutaneous pin/screw placement accuracy. This would be most applicable to external fixator pin placement in the pelvis.

The presence of pins described as "breach" demonstrates the risk of pin skiving during placement. Avrumova et al. found that the anatomy of the bony target, surrounding soft tissues, large angle to the bone surface at the starting point, and trajectory along the long axis of the cortical surface can increase the risk of skiving during pedicle screw insertion.7 The oblique surface of the posterior ilium may increase the risk of skiving during pin placement, so surgeons must take care to avoid damaging surrounding structures. To minimize the risk of skiving, surgeons may utilize high-speed drills, anti-skive pins, or a burr to prepare the pin starting point.

Prior research has demonstrated that reference frame location does not alter the occurrence of pedicle screw perforation. Ultimately, the location of the reference frame does not matter as long as the frame remains undisturbed.11,12 A prospective study by Ilsar et al. compared fluoroscopic navigation accuracy when the DRF was attached to bone versus mounted to a fracture table and showed no significant difference between the two placement locations.13 One drawback of not having an accurately placed frame or one contained completely within bone is the potential for displacement even with minimal disruption, which has the potential to disrupt the accuracy of final implant placement when navigation is utilized. When percutaneous pins, wires, or screws are placed as definitive fixation, their accuracy affects quality and maintenance of reduction/fixation. Additionally, when percutaneous pins are placed in higher-risk areas, including the pelvis where large neurovascular structures are located, there is potential for damage to these structures if placement is inaccurate. In the specific case of DRF placement, it may be beneficial to have pins that breach the medial or lateral cortex, providing bicortical fixation and improved stability.

The limitations of this study include that the graders were unable to review the entire CT scans and instead relied on a limited number of frames to determine pin grade. Graders were also forced to classify pins into one of three specific placement categories of the developed grading scheme, so there was imperfect interobserver reliability for pins that may have been borderline in terms of placement (Fig. 2D). Patients whose reference frame pins were not adequately visualized on the intraoperative CT scan or unable to be captured on several frames of the CT scan were excluded; this created a potential for selection bias. This would have been present whether the majority of cases did not have ideal placement or had ideal placement. However, because we were unable to classify these pins, we cannot make a statement as to how this would have altered the results. All pins were placed by one surgeon; as such, the accuracy of placement demonstrated in this study may not be applicable to surgeons with less experience placing pins for reference frames. Lastly, one area for improvement is identification of additional factors that may affect accuracy of pin placement. This study sought to analyze specific factors, including male sex and BMI. There are a multitude of other factors, including bone density, amount of adiposity over the posterior pelvis, angle of the ilium in the axial plane, and size of the intraosseous corridor, that may affect the accuracy of percutaneous pin placement and may be addressed in future validity studies utilizing our grading system.

Conclusions

This is the first paper to assess and develop a grading scheme for percutaneous pin placement into the pelvis. Additionally, this study demonstrated that, even in the hands of an experienced surgeon, nonideal placement occurred in around one-quarter of patients; however, a complete miss was rare. Male patients were significantly more likely to have ideal pin placement than females; however, BMI was not associated with pin placement accuracy. When placing percutaneous pins, regardless of the location, surgeons must be aware of factors that can decrease the accuracy of pin placement.

Acknowledgments

We thank Paul Lender for assistance with statistical analysis.

Disclosures

Dr. Sembrano reported grants from NuVasive and Orthofix outside the submitted work. Dr. Cheng is employed as the editor of JBJS Essential Surgical Techniques and serves on the medical board of trustees of MTF Biologics outside the submitted work. Dr. Jones reported grants from Medtronic and SI Bone outside the submitted work; and consulting fees from Medtronic and SI Bone unrelated to this work. Dr. Martin reported grants from SI Bone, AO Spine, and Mizuho Orthopedic Systems outside the submitted work; and personal fees from Medtronic outside the submitted work. Dr. Polly reported personal fees from SI Bone and Globus and grants from Medtronic and Mizuho OSI outside the submitted work; reported institutional research support from Medtronic and Mizuho OSI; and is a consultant for Globus.

Supplemental Information

Previous Presentations

The abstract was presented at the North American Spine Society 36th Annual Meeting, Boston, MA, September 29 to October 2, 2021, and the Society for Minimally Invasive Spine Surgery Annual Forum, Las Vegas, NV, September 29 to October 1, 2022.

Author Contributions

Conception and design: Comadoll, Jones, Martin, Polly. Acquisition of data: Comadoll, Sembrano, Ogilvie, Cheng, Jones, Martin, Polly. Analysis and interpretation of data: Comadoll, Haselhuhn, Sembrano, Cheng, Martin, Polly. Drafting the article: Comadoll, Haselhuhn. Critically revising the article: Comadoll, Haselhuhn, Sembrano, Cheng, Jones, Polly. Reviewed submitted version of manuscript: Comadoll, Haselhuhn, Sembrano, Ogilvie, Cheng, Jones, Polly. Approved the final version of the manuscript on behalf of all authors: Comadoll. Study supervision: Polly.

References

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    Polly DW Jr, Holton KJ. Minimally invasive sacroiliac joint fusion: a lateral approach using triangular titanium implants and navigation. JBJS Essent Surg Tech. 2020;10(4):e19.00067.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Lee DJ, Kim SB, Rosenthal P, Panchal RR, Kim KD. Stereotactic guidance for navigated percutaneous sacroiliac joint fusion. J Biomed Res. 2016;30(2):162167.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Van de Kelft E, Costa F, Van der Planken D, Schils F. A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation Navigation. Spine (Phila Pa 1976). 2012;37(25):E1580E1587.

    • Crossref
    • PubMed
    • Search Google Scholar
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  • 4

    Cawley D, Dhokia R, Sales J, Darwish N, Molloy S. Ten techniques for improving navigated spinal surgery. Bone Joint J. 2020;102-B(3):371-375.

  • 5

    Takao M, Hamada H, Sakai T, Sugano N. Factors influencing the accuracy of iliosacral screw insertion using 3D fluoroscopic navigation. Arch Orthop Trauma Surg. 2019;139(2):189195.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Grossterlinden L, Rueger J, Catala-Lehnen P, et al. Factors influencing the accuracy of iliosacral screw placement in trauma patients. Int Orthop. 2011;35(9):13911396.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Avrumova F, Morse KW, Heath M, Widmann RF, Lebl DR. Evaluation of K-wireless robotic and navigation assisted pedicle screw placement in adult degenerative spinal surgery: learning curve and technical notes. J Spine Surg. 2021;7(2):141154.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159174.

  • 9

    Holste KG, Zaki MM, Wieland CM, Saadeh YS, Park P. The impact of misplaced percutaneous iliac dynamic reference frame pins used during navigated spine surgery: incidence and outcomes. J Neurosurg Spine. 2022;37(2):208212.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Wang M, Jacobs RC, Bartlett CS, Schottel PC. Iliac dysmorphism: defining radiographic characteristics and association with pelvic osseous corridor size. Arch Orthop Trauma Surg. Published online February 17, 2022. doi:10.1007/s00402-022-04376-7

    • Search Google Scholar
    • Export Citation
  • 11

    Lin HH, Lu YH, Chou PH, Chang MC, Wang ST, Liu CL. Is bony attachment necessary for dynamic reference frame in navigation-assisted minimally invasive lumbar spine fusion surgery?. Comput Assist Surg (Abingdon). 2019;24(1):712.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Cho JY, Chan CK, Lee SH, Lee HY. The accuracy of 3D image navigation with a cutaneously fixed dynamic reference frame in minimally invasive transforaminal lumbar interbody fusion. Comput Aided Surg. 2012;17(6):300309.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Ilsar I, Weil YA, Joskowicz L, Mosheiff R, Liebergall M. Fracture-table-mounted versus bone-mounted dynamic reference frame tracking accuracy using computer-assisted orthopaedic surgery—a comparative study. Comput Aided Surg. 2007;12(2):125130.

    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand

Illustration from Chan et al. (E2). © Andrew K. Chan, published with permission.

  • View in gallery
    FIG. 1.

    Grading scheme for pin placement.

  • View in gallery
    FIG. 2.

    Pin placement examples. A: Ideal placement. B: Medial breach. C: Complete miss. D: Poor interobserver reliability.

  • 1

    Polly DW Jr, Holton KJ. Minimally invasive sacroiliac joint fusion: a lateral approach using triangular titanium implants and navigation. JBJS Essent Surg Tech. 2020;10(4):e19.00067.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Lee DJ, Kim SB, Rosenthal P, Panchal RR, Kim KD. Stereotactic guidance for navigated percutaneous sacroiliac joint fusion. J Biomed Res. 2016;30(2):162167.

    • Search Google Scholar
    • Export Citation
  • 3

    Van de Kelft E, Costa F, Van der Planken D, Schils F. A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation Navigation. Spine (Phila Pa 1976). 2012;37(25):E1580E1587.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Cawley D, Dhokia R, Sales J, Darwish N, Molloy S. Ten techniques for improving navigated spinal surgery. Bone Joint J. 2020;102-B(3):371-375.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Takao M, Hamada H, Sakai T, Sugano N. Factors influencing the accuracy of iliosacral screw insertion using 3D fluoroscopic navigation. Arch Orthop Trauma Surg. 2019;139(2):189195.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Grossterlinden L, Rueger J, Catala-Lehnen P, et al. Factors influencing the accuracy of iliosacral screw placement in trauma patients. Int Orthop. 2011;35(9):13911396.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Avrumova F, Morse KW, Heath M, Widmann RF, Lebl DR. Evaluation of K-wireless robotic and navigation assisted pedicle screw placement in adult degenerative spinal surgery: learning curve and technical notes. J Spine Surg. 2021;7(2):141154.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159174.

  • 9

    Holste KG, Zaki MM, Wieland CM, Saadeh YS, Park P. The impact of misplaced percutaneous iliac dynamic reference frame pins used during navigated spine surgery: incidence and outcomes. J Neurosurg Spine. 2022;37(2):208212.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Wang M, Jacobs RC, Bartlett CS, Schottel PC. Iliac dysmorphism: defining radiographic characteristics and association with pelvic osseous corridor size. Arch Orthop Trauma Surg. Published online February 17, 2022. doi:10.1007/s00402-022-04376-7

    • Search Google Scholar
    • Export Citation
  • 11

    Lin HH, Lu YH, Chou PH, Chang MC, Wang ST, Liu CL. Is bony attachment necessary for dynamic reference frame in navigation-assisted minimally invasive lumbar spine fusion surgery?. Comput Assist Surg (Abingdon). 2019;24(1):712.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Cho JY, Chan CK, Lee SH, Lee HY. The accuracy of 3D image navigation with a cutaneously fixed dynamic reference frame in minimally invasive transforaminal lumbar interbody fusion. Comput Aided Surg. 2012;17(6):300309.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Ilsar I, Weil YA, Joskowicz L, Mosheiff R, Liebergall M. Fracture-table-mounted versus bone-mounted dynamic reference frame tracking accuracy using computer-assisted orthopaedic surgery—a comparative study. Comput Aided Surg. 2007;12(2):125130.

    • Search Google Scholar
    • Export Citation

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