Fluoroscopy Research Articles

Ultrasound-guided vs. fluoroscopy-guided percutaneous leverage reduction for severely displaced radial neck fractures in children: a comparative analysis of clinical and radiological outcomes

BackgroundUltrasound (US) is a promising alternative to fluoroscopy (FL) for guiding percutaneous leverage reduction of displaced radial neck fractures in children. However, few studies have compared these modalities. This study aims to compare both the accuracy and efficacy of FL-guided versus US-guided percutaneous pinning in the treatment of radial neck fracture.MethodsSeventy-three children with displaced radial neck fractures were consecutively enrolled and assigned to the US or FL group. In all the patients, fractures were reduced with the percutaneous pin leverage technique. The patients were divided into two groups: the FL-guided group and the US-guided group. Baseline information, radiographs, and clinical results according to the criteria suggested by Metaizeau and complications were analyzed. Final Metaizeau criteria were categorized into excellent, good, fair, and poor.ResultsThe success rates for closed reduction were 100% for the US group and 91.2% for the FL group. The US group exhibited a significantly shorter operation time compared to the FL group (24.77 ± 8.00 min vs. 42.21 ± 15.18 min; P < 0.01). Additionally, the US group had a significantly lower number of FL images and radiation dose (3.59 ± 1.57 times, 9.56 ± 6.08 mGy) than the FL group (22.26 ± 8.07 times, 69.68 ± 34.70 mGy; P < 0.001). Reduction quality did not significantly differ between the groups according to the Metaizeau reduction classification (P = 0.130). According to the Metaizeau classification criteria, there was no significant difference between the two groups, including post-operative complications.ConclusionUltrasound-guided techniques offer a viable alternative for the treatment of displaced radial neck fractures in paediatric patients by minimising radiation exposure, expediting operative time and facilitating reduction.Level of evidenceTherapeutic Level III.

Establishing national diagnostic reference levels in fluoroscopy and fluoroscopically guided interventions in Ireland and comparing these with national diagnostic reference levels in Europe and internationally.

The purpose of this work was to establish national Irish diagnostic reference levels (DRLs) for a clinically representative and comprehensive list of clinical indications, anatomical regions, and common procedures for fluoroscopy and fluoroscopically guided interventions and compare these, where possible, to other DRLs established at a national level. A list of clinical indications, anatomical regions and common procedures was established. A national database of service providers was used to identify all medical radiological facilities providing fluoroscopy and fluoroscopically guided intervention services. These facilities were issued with an online survey. National Pka DRLs were set as the 75th percentile of the distribution of median values obtained. A national median dose was also established which is the 50th percentile of the median doses provided by facilities for the same patients and conditions as the national DRL value. The broad categorisation of equipment type was also considered. Where statistically significant differences were found between different detector types, detector specific national DRLs were established (flat panel detector and image intensifier specific DRLs). National Pka DRLs were established for 52 fluoroscopy and fluoroscopically guided intervention clinical indications, anatomical regions, and procedures. In addition, equipment specific (flat panel detector and image intensifier based systems) adult DRLs were established for the EVAR and lumbar puncture under fluoroscopy procedures. Paediatric DRLs were established for two fluoroscopy and fluoroscopically guided intervention clinical indications, anatomical regions, and procedures across various weight categories. Comparisons with other nationally set DRLs and other relevant literature suggest that Irish DRLs are typically lower than those established elsewhere. This work provided a unique opportunity to establish national DRLs based on census data for a wide range of clinical indications, anatomical regions, and procedures across adult and paediatric fluoroscopy and fluoroscopically guided interventions. Where comparisons with other nationally established work was possible Irish values are largely below other DRLs.

Calculation of CT ideal screw path and safety angle before percutaneous sacroiliac screw placement

IntroductionPercutaneous sacroiliac screw placement is the main surgical approach to treat unstable posterior pelvic ring injuries. Intraoperative fluoroscopic imaging is an important part of safe sacroiliac screw placement. However, how to determine the right perspective view is challenging. We developed a trigonometric algorithm to verify how preoperative pelvic computed tomography (CT) can be used to predict ideal screw path and safety angle.Materials and methodsThe normal pelvic CT data of 30 volunteers from our hospital between September 2021 and June 2023 were collected, and analyzed and reconstructed using Materialise Mimics 21.0. The angle between the cross-sectional ideal screw path and the horizontal plane (∠α), the angles of the pelvic inlet and outlet on the sagittal plane (∠1, ∠2), and the insertion angles of virtual screws at the inlet and outlet (∠a, ∠b) were measured. The ideal insertion angles (∠A, ∠B) and safety angles of the screws at the pelvic inlet and outlet were calculated using trigonometric functions.ResultsThe virtual screw insertion angle ∠a of 30 pelvises measured at the inlet was 18.57 ± 4.33°, and the ideal screw angle ∠A calculated using trigonometric functions was 18.72 ± 4.71° (range, 13.84 ± 0.75°-23.36 ± 0.98°). The difference between the measurement and calculation was only 0.15 ± 0.19° and not significant. The angle ∠b of the virtual screw insertion measured at the outlet was 25.37 ± 5.13°, and the ideal screw angle ∠B calculated using trigonometric functions was 25.58 ± 4.93 ° (range, 19.02 ± 0.88°-31.31 ± 1.01°). The difference between the measurement and calculation was only 0.20 ± 0.13° and not significant. The distance e from the optimal screw insertion point to the vertical line through the anterior superior iliac spine is 32.34 ± 1.76 mm, and the distance f to the horizontal line through the posterior superior iliac spine is 28.61 ± 0.81 mm.ConclusionsDuring preoperative planning, trigonometric calculations were used to determine the ideal screw placement angles and safety angle at the inlet and outlet of the screw path. Combined with intraoperative C-arm fluoroscopy, individualized screw insertion can help orthopedic surgeons quickly and accurately obtain intraoperative images and accurately determine the direction of screw insertion.

Lateralized reverse shoulder arthroplasty shows similar scaption kinematics but greater scapular neck-insert distance during external rotation compared to Grammont prosthesis.

[BACKGROUND]: Biomechanical differences between reverse shoulder arthroplasty (RSA) designs, specifically those with larger neck-shaft angles like the Grammont-type prosthesis and those with smaller neck-shaft angles such as lateralized humerus RSAs, have been analyzed in ex vivo studies. However, there is limited data on the differences in in vivo shoulder kinematics between these designs. The purpose of this study was to analyze in vivo kinematics of lateralized humerus RSA during active scaption and external rotation at the side, and to compare them to previously reported data for Grammont-type RSA. [METHODS]: Twenty shoulders that underwent RSA using a lateralized onlay prosthesis were included in this study. They consisted of 10 males and 5 females with a mean age of 76 years (range, 69-83). Patients underwent fluoroscopy during active scaption and external rotation at the side at or after postoperative 1 year; additionally, computed tomography was performed to create three-dimensional scapular implant models. Using these fluoroscopic images and three-dimensional models, three-dimensional shoulder kinematics were computed using model-image registration techniques. Scaption kinematics and scapular-neck distance were compared with data from previous studies on Grammont-type RSA, which were analyzed using the same techniques as in this study. [RESULTS]: There were no significant differences in scaption kinematics between lateralized humerus and Grammont-type RSA. However, the scapular neck-insert distance during active external rotation at the side was significantly greater in lateralized humerus RSA (3.2-5 mm) than in Grammont-type RSA (approximately 1 mm, P < .001) despite the glenohumeral abduction angles being significantly smaller (P = .03). [CONCLUSION]: Lateralized humerus RSA showed similar scaption kinematics to Grammont-type RSA; however, the scapular neck-insert distance during active external rotation at the side was significantly greater in lateralized humerus RSA than in Grammont-type RSA. The greater neck-insert distance may contribute to a lower incidence of scapular notching.

A miniaturized cooling system for trans-esophageal echocardiographic probes may improve patients safety in minimally invasive cardiac surgery or trans-catheter percutaneous interventions

Abstract Introduction The recent development of real-time three-dimensional trans-esophageal echocardiography (RT-3D TEE) has favoured a wider transition from open-heart to minimally invasive surgery (MIS) or various trans-catheter percutaneous interventions, minimizing surgical risks and allowing faster post-operative and procedural discharge [1]. However, recent studies have highlighted the potential risk of oesophageal lesions partly related to thermal injury caused by the heat of the TEE probe during cardiac interventions [2]. Purpose This work aims to design a cooling system for trans-esophageal echocardiographic probes to be used during MIS or trans-catheter procedures. Currently during those interventions, fluoroscopic and RT-3D TEE images are simultaneously used, since commercial TEE probes automatically switch off at a temperature threshold of approximately 42.5°C [3], to avoid potential thermal oesophageal lesions. Additionally, ultrasound (US) image quality tends to decrease as temperature increases. The creation of a cooling device for TEE probes would therefore increase the reliability of US images in the intraoperative context, also considering their complete harmlessness to the patient. Methods The proposed cooling system design is a silicone cap – thus potentially sterilisable and reusable - into which the probe is inserted. The cap has an inner tube in which water flows at 25°C, constituting the cooling fluid. Heat exchange was studied through thermo-fluid dynamic simulations to analyse the cooling phenomenon. The hydraulic flow is controlled by a pumping device that activates when the probe temperature reaches a specific threshold deemed to be critical, also for image quality. Temperature trends are constantly monitored by means of two thermistors. Results The cooling system was extensively tested (5 repetitions for each experimental condition: Probe alone, Passive silicone and Active cooling system) on a probe produced by GE Healthcare, setting 38°C as the activation temperature threshold for the pump. Considering the duration of MIS or transcatheter interventions (about two hours) [2], it was experimentally observed that by using the cooling system the probe never exceeded the temperature of 39°C. From experimental tests, it is possible to state that the insulating properties of silicone result in a dual effect: a) silicone passively hinders heat dispersion produced by the probe due to the Joule effect - Passive silicone condition ; b) once the system is activated the cooling effect is maintained by the precence of water inside the cap - Active cooling system condition. Conclusions In conclusion, based on numerical simulations and experimental results, this novel tool seems promising, increasing the safety and potentially also the reliability of US images in the intraoperative and intraprocedural scenario. Cooling system design Experimental results

A comparative study to evaluate radiation exposure in patent ductus arteriosus device closure by conventional method and echocardiography guided method- an experience from eastern India

Abstract Background PDA constitutes 5-10% of all congenital heart defects, with a prevalence of symptomatic PDA being 0.5/1000 live births. Percutaneous PDA device closure has the advantage of early discharge and less anesthesia - related complications. However, during the procedure, the operators and patients are exposed to radiation. Use of transthoracic echocardiogram (TTE) for imaging during trans-catheter PDA closure reduces the dose of radiation, complications related to femoral arterial access and procedural time. In our institution we planned to compare the radiation exposure and procedural time of PDA device closure by transthoracic echocardiography with the use of minimal fluoroscopy(case) compared to conventional method(control) in pediatric patients. Purpose i)To compare the radiation exposure and procedural time of PDA device closure by transthoracic echocardiography with the use of minimal fluoroscopy(case) to conventional technique(control) in a tertiary care hospital. ii) To compare the complications between the two groups. Methods This was a single-centre prospective randomized case control study. Children between 6 months -12 years with an indication for percutaneous PDA device closure were selected after concsent. A six month post-operative follow up was planned. 106 patients were included in the study from July 2018 to January 2020. The first patient was selected through lottery who underwent the procedure under echocardiographic guidance with minimal fluoroscopy use and thereby every alternate patient was selected as case (n=51). 51 patients underwent closure following the conventional method(control). Each group were selected with comparable age group and other characteristics. 4 patients in the case arm had to undergo aortogram, so excluded from the study. Results Patients were equally distributed in both groups. There was statistically significant difference in the procedural time, fluoroscopy time and radiation dose in terms of total kerma, dose area product and dose area product/kg among the two groups, all of them were lower in the echocardiography group compared to fluoroscopy group.The least fluoroscopy time, radiation exposure and procedural time in the echocardiography group were 43 seconds, 1mGy, 20minutes respectively. Conclusion In both the groups the patient characteristics, defect size and device used was comparable. The fluoroscopy group had a single case of groin hematoma, managed conservatively. Fluoroscopy time, procedural time and amount of radiation exposure in TTE guided group was significantly less than the control group. In echocardiography group, no contrast was used and all the possible arterial access related complications were easily prevented. Above results show that it is safe and feasible to perform PDA device closure with TTE-guided percutaneous PDA occlusion as compared to conventional method with minimal fluoroscopy exposure.

Digging into the Cause of Abnormal Patellar Kinematics After Open-Wedge High Tibial Osteotomy via a Quantitative Study on In Vivo Soft Tissue Functional Changes

The biomechanical mechanism of postoperative patellofemoral joint (PFJ) complications after open-wedge high tibial osteotomy (OWHTO) has not been investigated. This study was to determine the length changes in the patellar tendon (PT), medial patellotibial ligament (MPTL), medial patellofemoral ligament (MPFL), and quadriceps moment arm (QMA) during staircase motion before and after OWHTO. Computed tomography (CT) scans of 15 patients’ lower extremities were used to reconstruct three-dimensional models, and magnetic resonance imaging (MRI) of the knee and hip joints was used to mark the soft tissue footprints. Then, such soft tissue lengths were quantified by a dual fluoroscopic imaging system (DFIS). Additionally, function scores were used to assess patient outcome changes. The results showed that there was a contraction of the PT after OWHTO due to its adhesion to the osteotomy site, causing PT length to be negatively correlated to the open-wedge angle. In addition, the shortening of the MPTL and QMA caused patellar instability and an imbalance in the strength of the lower extremities. Additionally, most knee function scores improved after OWHTO, except the Feller scores. Multiple methods should be considered to optimize surgical procedures, postoperative rehabilitation, and physical therapy.

Validation of UniverSeg for Interventional Abdominal Angiographic Segmentation.

Automatic segmentation of angiographic structures can aid in assessing vascular disease. While recent deep learning models promise automation, they lack validation on interventional angiographic data. This study investigates the feasibility of angiographic segmentation using in-context learning with the UniverSeg model, which is a cross-learning segmentation model that lacks inherent angiographic training. A retrospective review, after IRB approval, identified 234 patients who underwent interventional fluoroscopy of the celiac axis with iodinated contrast from January 1, 2019, to December 31, 2022. From 261 acquisitions, 303 maximum contrast images were selected, each generating a 128 × 128 pixel partition for arterial detail analysis and binary mask creation. Image-mask pairs were divided into three classes of 101 pairs each, based on arterial diameter and bifurcation number. UniverSeg was tested class independently in a fivefold nested cross-validation. Performance analysis for in-context learning determined average model convergence for class sizes from 1 to 81 pairs. The model was further validated by repeating the tests on the inverse segmentation task. Dice similarity coefficients for decreasing diameters were 78.7%, 72.5%, and 59.9% (σ = 5.96, 7.99, 14.29). Balanced average Hausdorff distances were 0.86, 0.71, and 1.16 (σ = 0.37, 0.52, 0.68) pixels, respectively. Inverted mask testing aligned with UniverSeg expectations for out-of-context problem sets. Performance improved with support class size, vessel diameter, and reduced bifurcations, plateauing to within ± 1.34 Dice score at N = 51. This study validates UniverSeg for arterial segmentation in interventional fluoroscopic procedures, supporting vascular disease modeling and imaging research.

Feasibility of robot-assisted system for navigated needle positioning in the PCNL procedure in vitro.

The objective of this study was to explore the feasibility of using the TianJi Robot system for navigated needle positioning in the PCNL procedure in vitro. A pig kidney with a segment of ureter was selected as the in vitro organ model. Iodine contrast agent was infused into the renal pelvis to dilate the renal pelvis and calyx to establish the in vitro hydronephrosis model. Fluoroscopic images were obtained using a 3D C-arm and transferred to the robotic workstation. Three-dimensional reconstructed images were generated and displayed on the monitor screen. The surgeon planned the optimal puncture trajectory on the workstation. After that, the robotic arm was instructed to move to the surgical field. The guiding cannula was placed onto the robotic arm and brought close to the skin. The needle was placed along the guiding cannula. An 18G needle was inserted manually. Finally, a second CBCT scan was performed to validate the needle's location. Three hydronephrosis models were used in the study, and a total of seven target calyces were planned. six target calyces were successfully punctured in one attempt, with a single-puncture success rate of 87.5%. A high single-puncture success rate is achieved using the TianJi Robot system for navigated needle positioning in the PCNL procedure in vitro, marking an innovative step forward in urological interventions.

A systematic review of the effectiveness of leaded glasses for ensuring safety among healthcare professionals in fluoroscopy.

Currently, there is an increase in procedures across various clinical specialties involving the use of ionising radiation. The primary objective of this systematic review is to analyse and compare the existing literature regarding the effectiveness of leaded glasses for healthcare professionals. Comprehensive literature searches were conducted for relevant studies published between 2018 and 2023 using the Scopus, PubMed, and Web of Science databases according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology. After the complete text screening, 11 articles were deemed suitable for inclusion in the review. Leaded glasses significantly reduce eye radiation exposure, with studies showing shielding effects ranging from 10 % to 88,9 %, depending on the configuration and thickness of the glasses. For instance, lightweight glasses achieved a shielding effect of 61.4 %, while thicker lead equivalents (≥0.5 mm) offered up to ninefold dose reductions. Studies also noted the importance of lateral shielding and ergonomic designs for optimal protection. Leaded glasses significantly reduce eye lens doses but are most effective when combined with other protective measures. Factors such as head orientation, procedural complexity, and operator movement influence their performance. The findings underscore the need for standardised guidelines on protective eyewear use and further research under real-world clinical conditions. It is essential to ensure the proper use of leaded glasses to minimize the risks of ionising radiation for healthcare professionals in fluoroscopy procedures.

HKA angle exceeding 5 degrees is strongly associated with lateral patellar translation beyond 2 mm: surgical recommendations for avoiding adverse effects on the patellofemoral joint after OWHTO

PurposePrevious studies reported that anterior knee pain (AKP) occurs with an incidence of 32% after opening-wedge high tibial osteotomy (OWHTO). However, the biomechanical effects of this procedure on patellofemoral joints (PFJs) remain unclear. We aimed to quantify the changes in the kinematics and cartilage conditions of the PFJ during stair climbing before and after OWHTO.MethodsWe recruited 15 patients who underwent unilateral OWHTO. All patients performed continuous stair climbing under the surveillance of a dual fluoroscopic imaging system to determine accurate 6-degree-of-freedom (6-DOF) PFJs and 3D hip-knee-ankle (HKA) angles before and 6 months after OWHTO. The volume penetration centres between the patellar and femoral cartilage models were defined as contact centres. Eleven of these patients underwent quantitative T2 relaxation MRI to determine whether and how PFJ cartilage degeneration progressed.ResultsAfter OWHTO, patella valgus (mean − 3.73°, P = 0.02) and internal rotation (mean 3.14°, P = 0.03) increased compared with the preoperative conditions during the stair climbing motion. In addition, the patellae of OWTHO knees were located more laterally after surgery (1.56 ± 2.24 mm, P = 0.02) at knee flexion. Moreover, lateral shifts in the contact patterns of both the medial and lateral patellar facets together with increased T2 values (207.10 ± 21.84 ms, P = 0.04) of the lateral patella cartilage were found after surgery. Finally, the lateral patellar shift increased with decreasing varus 3D-HKA after surgery (R= -0.79, P < 0.001). Therefore, controlling 3D-HKA may be helpful in limiting lateral patellar shift.ConclusionOWHTO changed the patellofemoral kinematics and contact patterns during stair climbing, especially the lateral patellar shift, which may lead to degeneration of the PFJ cartilage. Avoiding overcorrection of the HKA angle beyond 5 degrees of valgus reduces lateral patellar translation, which may help prevent AKP. Additional clinical studies are necessary to validate these biomechanical findings and clarify their impacts on patient outcomes.

Accuracy of a Superficial Landmark of the Recurrent Branch of the Median Nerve and Anatomical Features of Transverse Muscle Fibres Observed During Carpal Tunnel Release.

Background: Surgeons use anatomical landmarks like the scaphoid tubercle, pisiform, trapezial tubercle and hook of hamate, along with Kaplan cardinal line (KCL) to avoid injury to the recurrent motor branch (RMB) of the median nerve during carpal tunnel release. The presence of transverse muscle fibres (TMF) overlying the transverse carpal ligament (TCL) may suggest proximity of the RMB, but their anatomical relationship is unclear. In this study, we evaluated the accuracy of anatomical landmarks to the RMB, TMF origin and insertion, and examined the relationship between TMF presence and RMB running patterns. Methods: We dissected 30 hands from 16 fresh-frozen cadavers. After marking the superficial landmarks, we made a skin incision to confirm the presence of TMF and examined their origins and insertions. We then opened the carpal tunnel, dissected the RMB and recorded each position on a coordinate system using a fluoroscopic imaging system. Results: TMF were observed in 18 hands (60%): 13 were continuous with the abductor pollicis brevis (APB), 2 were continuous with the superficial head of the flexor pollicis brevis (FPB) and 3 were continuous with both. The bifurcation point of the RMB was significantly located 4.5 mm ulnar and 7.5 mm proximal to the superficial landmark at the median. The RMB was classified according to Poisel classification: 24 (80%) were of the extraligamentous type, 4 (13%) of the transligamentous type, 1 (3%) of the preligamentous type and 1 (3%) of the subligamentous type. Amongst these, the transligamentous/preligamentous/subligamentous types are at high risk for RMB injury during TCL incision. No significant association existed between TMF presence and these high-risk RMB types.. Conclusions: The actual RMB may be located ulnar and proximal to the superficial landmark, indicating that surgeons should be cautious about RMB damage even in the absence of TMF.

Development of a Deep Learning Model for Automating Implant Position in Total Hip Arthroplasty.

Novel methods for annotating antero-posterior (AP) pelvis radiographs and fluoroscopic images with deep-learning models have recently been developed. However, their clinical use has been limited. Therefore, the purpose of this study was to develop a deep learning model that could annotate clinically relevant pelvic landmarks on both radiographic and fluoroscopic images and automate total hip arthroplasty (THA)-relevant measurements. A deep learning model was developed using imaging from 161 primary THAs. A combination of preoperative and postoperative AP pelvis radiographs and intraoperative fluoroscopic images were annotated. A landmark detection model was then designed to annotate pelvis radiographs and fluoroscopic images. The algorithm was used to automate the measurement of pelvic tilt, leg length, offset, acetabular component abduction, and inclination. Our novel deep learning model annotated pelvic landmarks as well, if not better, than trained humans at 16 of 20, four of four, and five of eight landmarks for bony landmarks on radiographs, implant landmarks on radiographs, and bony landmarks on fluoroscopy, respectively. Measurements of cup inclination and anteversion, pelvic tilt, offset, and leg length were successfully calculated. We have developed a novel deep-learning model that can automate the identification of clinically relevant pelvic landmarks in real time and provide THA-relevant measurements that are equivalent to those of trained humans. We believe the model could be rapidly incorporated into clinical practice for both surgical and research applications.

Pathology and Acute Phase Treatment of Osteoporotic Vertebral Fractures:Indications and Techniques for Vertebroplasty

Vertebroplasty has shown excellent analgesic effects in patients with osteoporotic vertebral fractures. In Japan, percutaneous vertebroplasty, balloon kyphoplasty, and vertebral body stenting are commonly performed. All of these techniques require precise transpedicular vertebral puncture and complete cement filling without leakage. Puncture should only be performed after accurately identifying the upper and lower end plates of the vertebral body, lateral borders, and pedicles using combined frontal and lateral fluoroscopic images. In the frontal view, the puncture was made from the lateral cranial side of the pedicle toward the center of the vertebral body. In the lateral view, before passing through the medial wall, the tip had entered the vertebral body and advanced to the anterior quarter. Bone cement within the vertebral body can permeate the trabecular spaces or accumulate as a single mass. To prevent leakage, the movement of the injecting finger should be aligned precisely with the fluoroscopic images. Awareness of the three leakage patterns and basivertebral, segmental, and cortical veins, is crucial. Potential lateral leakage outside the vertebral body must be focused. The injection was terminated as the cement reached the posterior quarter.

Radiological safety atlas of minimally invasive midfoot fusion: A cadaver study.

The popularity of minimally invasive (MIS) foot surgery continues to grow. However, it comes with certain limitations that present notable challenges. One significant hurdle is the absence of direct visualization of neurovascular structures and tendons. The objective of this study is to present fluoroscopic heatmaps that illustrate the trajectories of major structures encountered during MIS midfoot procedures. Sequential dissection was performed on nine below-knee cadaveric specimens and critical structures were identified and marked, including anterior tibialis tendon (ATT), extensor hallucis longus tendon (EHL), extensor digitorum longus tendon (EDL), superficial peroneal nerve (SPN) and dorsal neurovascular bundle (DNVB) were dissected. Subsequently, flexible wires were positioned and securely placed adjacent to the medial and/or lateral borders of these structures to visualize their trajectories on X-ray imaging. Anteroposterior (AP) and oblique fluoroscopic images of the foot, featuring a calibration marker, were obtained alongside standard photographs. All fluoroscopy images were adjusted to a uniform scale and standardized to a single foot fluoroscopy. The coordinates of the structures were marked on these standardized foot AP and oblique fluoroscopic views. These coordinates were then utilized to generate heatmaps. Successfully generated heatmaps encompassed the DNVB, ATT, EDL, EHL, and SPN, on AP and oblique fluoroscopic images of the foot. The color gradient used visually represents varying magnitudes, with red indicating the most frequent locations of the structures and blue signifying lower occurrences. These heatmaps also illustrate the highest-risk areas for iatrogenic injury to the structures during MIS procedures. This study can empower surgical navigation and improve safety in MIS midfoot procedures by providing surgeons with a fluoroscopic heatmap detailing the trajectories of major anatomical structures. The findings from this study present a valuable opportunity to improve surgical accuracy and safety.

Assessing the Impact of Patient-Specific Instrumentation and Fixation on Accuracy and Radiation Exposure in a Cadaveric Model of Medial Opening-Wedge High Tibial Osteotomy.

Traditional freehand techniques in high tibial osteotomy (HTO) have been shown to lack precision and accuracy. Patient-specific instrumentation (PSI) and fixation created from cross-sectional imaging have recently been introduced to address this problem. The purpose of the study was to compare traditional freehand techniques versus PSI in a human cadaveric model of HTO. It was hypothesized that the osteotomies performed using PSI would require less radiation exposure for operating room staff and would reduce deviation from the planned correction in the coronal, sagittal, and axial planes. Controlled laboratory study. Sixteen matched cadaveric knees underwent medial opening-wedge HTO via the freehand method (n = 8) or PSI technique (n = 8) with a predetermined planned opening-wedge size. Computed tomography was used to measure the achieved wedge size as well as alignment parameters in the coronal, sagittal, and axial planes. Radiation dose, number of fluoroscopic images taken, and total operative time were recorded. The mean deviation from the planned wedge size was smaller in the PSI group compared with the freehand group (0.505 vs 3.016 mm, respectively; P < .01). Total radiation dose to medical staff (0.85 vs 2.04 mGy; P < .01) and number of fluoroscopic images (15.5 vs 41; P < .01) were also smaller in the PSI versus the freehand group, respectively. No difference was seen in total operative time between the 2 groups (P = .62). In cadaveric specimens, the PSI technique demonstrated superior accuracy and decreased radiation exposure for medical staff compared with the traditional freehand technique without compromising operative efficiency. The use of PSI when HTO is performed can lead to more accurate operations and potentially improve outcomes.

Use of Augmented Reality Surgical Navigation Reduces Intraoperative Fluoroscopic Imaging in Anterior Total Hip Arthroplasty with Equivalent Accuracy for Component Positioning

Use of Augmented Reality Surgical Navigation Reduces Intraoperative Fluoroscopic Imaging in Anterior Total Hip Arthroplasty with Equivalent Accuracy for Component Positioning

Assessment of Catheter-Directed Thrombolysis and Histotripsy Treatment for Deep Vein Thrombosis.

The hypothesis of this study was histotripsy, an ultrasound therapy that disrupts tissue mechanically through the action of bubble clouds, increases the short-term rate of acute thrombus clearance for catheter-directed thrombolysis (CDT) in an animal model. Thrombi formed in the femoral vein of pigs were treated with CDT, histotripsy, or CDT and histotripsy (histotripsy+). Ultrasound (B-mode and color Doppler) and contrast fluoroscopy imaging data were scored by four observers for semi-quantitative evaluation of each arm with ordinal regression models. Further, B-mode images were manually annotated by three observers to quantify the thrombus clearance rate. A total of 27 thrombi (2.0 ± 0.4 cm in length) in 27 animals were considered in this study (N = 8 for CDT, N = 9 for histotripsy, and N = 10 for histotripsy+). The mean treatment duration was 20.2 ± 1.3 min. The ordinal regression models indicated the thrombus clearance rate was increased for histotripsy+ relative to CDT based on B-mode and color Doppler, but not fluoroscopy (p = 0.015, 0.001, and 0.900, respectively). Manual annotation of B-mode images denoted histotripsy+ had an increased thrombus clearance rate relative to CDT and histotripsy (p = 0.001 and 0.022, respectively). Petechial hemorrhage was present in the perivascular soft tissue for two cases with histotripsy and one case with histotripsy+. The clearance of acute thrombus was similar for treatment with CDT or histotripsy. Combining these individual approaches further increased the rate of thrombus clearance based on multiple imaging metrics.

Intra-Vertebral Contrast Phlebography During Balloon Kyphoplasty: A Cautionary Tale of Using Antegrade Inferior Vena Cavogram in Preventing Pulmonary Cement Embolism

Pulmonary embolism of cement is considered a catastrophic complication of kyphoplasty. Considering the predilection of thoracic and upper lumbar levels as well as the role of valveless vertebral plexus and abdominal caval system, we report the utility of performing an intra-osseous phlebography in the fractured vertebral body visualized through lateral view fluoroscopic cine-images to assess the direct contrast efflux towards the Inferior Vena Cava (IVC). The flow patterns of anterior external vertebral venous plexus and its tributaries are shown using schematic diagrams and fluoroscopic images. Stepwise technique of this perivertebral venogram is discussed as well as recognition of confounding paravertebral/ radiculomedullary arterial anatomy. The new venous channels opening up after balloon inflation are highly likely to be the surrogate pathways for cement embolization to the heart and pulmonary artery. This simple additional imaging step (“antegrade inferior vena cavogram”) helps to avoid anterior venous plexus extravasation of cement towards the IVC, using bipedicular contrast lavage and sequential injection using different viscosities. This article also highlights the management of pulmonary embolism using interventional radiology as well as open surgical methods. The article also eludes into some alternate vertebral augmentation device strategies to achieve complete obviation of cement extravasation as well.

Does Orthopaedic Resident Pelvis Fluoroscopy Knowledge improve with testing with a Novel Pelvis Model and Educational website?

We tested whether residents would improve in fluoroscopy knowledge and ability after using an inexpensive novel pelvis model and educational website. Twenty-four orthopaedic residents were recruited from three United States residency programs and randomised into two groups with equal numbers of juniors and seniors. The OrthoAcademy group received educational materials from a website ( www.theorthoacademy.com ), whereas the control group did not. Survey scores, radiograph scores, number of fluoroscopic images taken, and overall radiation exposure were compared (1) between control and OrthoAcademy groups and (2) between junior and senior residents. Both groups had higher radiograph scores at the second round of testing than at the first (P =.004). The OrthoAcademy group had higher post-test than pre-test knowledge survey scores (P =.045), whereas the control group did not (P =.54). However, the OrthoAcademy group did not have higher radiograph scores between tests (P =.15), whereas the control group did (P =.01). Junior residents had higher second-round than first-round radiograph scores (P =.005) and survey scores (P =.006), whereas senior residents did not (P =.24 radiograph scores) (P =.30 survey scores). Testing residents with this novel pelvis model improved the quality of the fluoroscopic images obtained by the residents, especially juniors. This study highlighted the need for more accessible resources for residents to learn about obtaining these images.