Fluoroscopic Reduction Research Articles

What Have We Learned in the Wrist Joint of Distal Radius Fracture through Wrist Arthroscopy?

Abstract Background Wrist arthroscopy is an efficient tool for the surgical treatment of distal radius fracture (DRF). It could show us the various conditions of the radiocarpal joint, its effectiveness seems to overwhelm that of fluoroscopy. Methods Since July 2005, we have performed wrist arthroscopy and plate presetting arthroscopic reduction technique (PART) for 141 extra-articular and 559 intra-articular DRFs and investigated various kinds of intra-articular conditions and advantages of wrist arthroscopy. Results The pathological conditions clarified and the advantages of PART in the surgical treatment of DRF are: (1) accurate reduction of intra-articular fragments is possible compared with fluoroscopic reduction, (2) intra-articular fragments (free body) undetected with radiograph and CT can be recognized, (3) screw protrusion into joint surface can be monitored, (4) intra-articular soft tissue injury associated with fracture can be evaluated and treated, and (5) debridement of joint hematoma can be performed. Severe complications such as tendon rupture, major neurovascular injury or compartment syndrome from arthroscopy were never encountered. Conclusions The volar locking plate fixation and simultaneous arthroscopic intervention is problematic because vertical traction must be applied and released during surgery. PART can overcome these difficulties and achieved good clinical results.

Impact of a 6–12-h delay between ileocolic intussusception diagnostic US and fluoroscopic reduction on patients’ outcomes

BackgroundImage-guided reduction of intussusception is considered a radiologic urgency requiring 24-h radiologist and technologist availability.ObjectiveTo assess whether a delay of 6–12 h between US diagnosis and fluoroscopic reduction of ileocolic intussusception affects the success frequency of fluoroscopic reduction.Materials and methodsRetrospective review of 0–5-year-olds undergoing fluoroscopic reduction for ileocolic intussusception from 2013 to 2023. Exclusions were small bowel intussusception, self-reduced intussusception, first fluoroscopic reduction attempt>12 h after US, prior bowel surgery, inpatient status, and patient transferred for recurrent intussusception. Data collected included demographics, symptoms, air/contrast enema selection, radiation dose, reduction failure, 48-h recurrence, surgery, length of stay, and complications. Comparisons between<6-h and 6–12-h delays after ultrasound diagnosis were made using chi-square, Fisher’s exact test, and Mann–Whitney U tests (P< 0.05 considered significant).ResultsOf 438 included patients, 387 (88.4%) were reduced in <6 h (median age 1.4 years) and 51 (11.7%) were reduced between 6 and 12 h (median age 2.05 years), with median reduction times of 1:42 and 7:07 h, respectively. There were no significant differences between the groups for reduction success (<6 h 87.3% vs. 6–12 h 94.1%; P-value = 0.16), need for surgery (<6 h 11.1% vs. 6–12 h 3.9%; P-value=0.112), recurrence of intussusception within 48 h after reduction (<6 h 9.3% vs. 6–12 h 15.7%; P-value=0.154), or length of hospitalization (<6 h 21:07 h vs. 6–12 h 20:03 h; P-value=0.662).ConclusionA delay of 6–12 h between diagnosis and fluoroscopic reduction of ileocolic intussusception is not associated with reduced fluoroscopic reduction success, need for surgical intervention after attempted reduction, recurrence of intussusception following successful reduction, or hospitalization duration after reduction.Graphical

Concomitant valgus hip osteotomy in operative fixation of displaced proximal femoral neck fractures.

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs). In the first series, 98 hip fixation procedures were performed using CCS. After fluoroscopic reduction of the fracture, three CCSs were placed. In the second series, 105 VOOF procedures were performed using a closing wedge intertrochanteric osteotomy with a compression lag screw and lateral femoral plate. The alignment goal was to create a modified Pauwel's fracture angle of 30°. After fluoroscopic reduction of fracture, lag screw was placed to achieve the calculated correction angle, followed by inter-trochanteric osteotomy and placement of barrel plate. Patients were followed for a minimum of two years. Mean follow-up was 4.6 years (4.1 to 5.0) in the CCS group and 5.5 years (5.25 to 5.75) in the VOOF group. The mean Harris Hip Score at two-year follow-up was 83.85 in the CCS group versus 88.00 in the VOOF group (p < 0.001). At the latest follow-up, all-cause failure rate was 29.1% in the CCS group and 11.7% in the VOOF group (p = 0.003). The total cost of the VOOF technique was 7.2% of a THA, and total cost of the CCS technique was 6.3% of a THA. The VOOF technique decreased all-cause failure rate compared to CCS. The total cost of VOOF was 13.5% greater than CCS, but 92.8% less than a THA. Increased cost of VOOF was considered acceptable to all patients in this series. VOOF technique provides a reasonable alternative to THA in patients who cannot afford a THA procedure.

Minimal invasions: is wrist arthroscopy supported by evidence? A systematic review and meta-analysis.

Wrist arthroscopy is used increasingly, but its benefits and harms are unclear. This systematic review aimed to identify all published randomized controlled trials on wrist arthroscopy and synthesize the evidence of the benefits and harms of wrist arthroscopic procedures. We searched CENTRAL, MEDLINE, and Embase for randomized controlled trials comparing wrist-arthroscopic surgery with corresponding open surgery, placebo surgery, a non-surgical treatment, or no treatment. We estimated the treatment effect with a random effect meta-analysis using patient reported outcome measure (PROM) as primary outcome where several studies assessed the same intervention. Of 7 included studies, none compared wrist arthroscopic procedures with no treatment or placebo surgery. 3 trials compared arthroscopically assisted reduction with fluoroscopic reduction of intra-articular distal radius fractures. The certainty of evidence was low to very low for all comparisons. The benefit of arthroscopy was clinically unimportant (smaller than what patients may consider meaningful) at all time points. 2 studies compared arthroscopic and open resection of wrist ganglia, finding no significant difference in recurrence rates. 1 study estimated the benefit of arthroscopic joint debridement and irrigation in intra-articular distal radius fractures, showing no clinically relevant benefit. 1 study compared arthroscopic triangular fibrocartilage complex repair with splinting in distal radioulnar joint instability in people with distal radius fractures, finding no evidence of benefits for repair at the long-term follow-up but the study was unblinded, and the estimates imprecise. The current limited evidence from RCTs does not support benefits of wrist arthroscopy compared with open or non-surgical interventions.

The Ratio of the Distal Femur Width to the Tibial Plateau Width with Advancing Age

Historically, intraoperative analysis of knee fracture procedures relied upon a fluoroscopic reduction assessment by the surgeon. This is a subjective assessment due to the lack of linear measurement reference data. Compared with the knee, the ankle and wrist have well-established bony anatomical relationships to guide reduction assessment during fracture treatment. The purpose of this study was to (1) determine the width ratios in the knee (plateau to femur) with aging, and (2) determine knee width changes with aging. One-hundred and fifty consecutive uninjured knee radiographs were reviewed. In all age groups, the width ratio of the articular distal femoral (ADF) to the articular tibial plateau (ATP) is greater than 1.0 and between 1.03 and 1.05. The tibia plateau width is on average 9.34 mm wider and the femoral width is 8.0 mm wider in the 61 to 80 age group than the ATP and the ADF in the younger age groups. In conclusion, the articular tibial plateau width and the articular distal femoral width are nearly equal across ages 20 to 80 years. An absolute articular width value by age cannot be assigned because articular widths change with aging.

Comparing Outcomes between Arthroscopic-Assisted Reduction and Fluoroscopic Reduction in AO Type C Distal Radius Fracture Treatment.

Background Distal radius fracture is one of the most common injuries. Poor functional result with restricted wrist motion can be developed when there is intra-articular fibrous tissue development arising from articular step-off and gapping. Objectives The aim of this study is to compare the functional and radiological outcome between arthroscopic-assisted reduction and fluoroscopic reduction in treating unstable intra-articular distal radius fracture. Methods We retrospectively analyzed 12 patients with intraarticular AO type C distal radius fracture treated with arthroscopic-assisted fracture reduction and internal fixation and compared them with another group of 12 patients in which fracture reduction is assessed by fluoroscopy alone (15 males and 9 females, mean age 57.3, range 27-73). The two cohorts were analyzed for differences in radiological parameters including articular stepping and gapping, palmar tilt, radial inclination, ulnar variance as well as functional outcome in range of motion, grip strength, modified mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score at an average of 12.5 months (range 5-26) after surgery. Results Arthroscopic-assisted fracture reduction group has statistically better restoration of articular stepping and gapping, volar tilt and ulnar variance. Range of motion, grip strength, modified mayo wrist score and Quick DASH score also had statistically significant improvement in arthroscopic group. Conclusion Our study showed arthroscopic-assisted technique can precisely restore radiological parameters in highly comminuted distal radius fracture with good functional outcome. Also, associated intra-articular soft tissue injury can be detected and treated simultaneously. Level of Evidence This is a level III, retrospective cohort study.

Diagnosis and Management of Pediatric Patients with Intussusception

AbstractIntussusception is one of the most common cause of bowel obstruction in infancy. While surgical intervention is sometimes needed, the primary modality for the reduction of intussusception is pneumatic or air enema. This is highly successful in the reduction of ileocolic intussusception with 90% success rate. Here we review the presentation, pathophysiology, appropriate radiographic studies and findings, and fluoroscopic reduction technique.

Ultrasound-Assisted Closed Reduction of Distal Radius Fractures

To assess the accuracy and ability of ultrasound for monitoring closed reduction for distal radius fractures. Consecutive patients undergoing ultrasound-guided closed reduction of acute, displaced distal radius fractures between January 2003 and December 2006 at our department were enrolled. The control group was extracted from patients who underwent a closed reduction for similar fractures under fluoroscopy or without any imaging assistance. To confirm the accuracy of the ultrasonography measurements, displacement distance values were compared with those on radiographic imaging before and after reduction. X-ray parameters for pre- and postreduction, reduction time, total cost, and success rate were compared between the ultrasound-guided and the control groups. The ultrasound-guided group consisted of 43 patients (mean age, 68 y) and the control group consisted of 57 patients, which included 35 patients (mean age, 74 y) with fluoroscopic reduction and of 22 patients (mean age, 72 y) with reduction unaided by imaging. There were no significant displacement differences between radiographic and ultrasound measurements. In x-ray parameters for pre- and postreduction, there were no significant differences between the 2 groups. Ultrasound-guided reduction took longer than the other 2 methods. The success rate of the ultrasound and the fluoroscopic groups were similar (95% and 94%, respectively). Our data suggest that ultrasound assistance can aid reduction of distal radius fractures as well as fluoroscopy. Therapeutic II.

Intussusception Revisited: Is Immediate On-Site Surgeon Availability at the Time of Reduction Necessary?

The American College of Radiology recommends that fluoroscopically guided intussusception reduction be performed with a surgeon readily available. At many institutions, this may not be feasible. The purpose of this study was to assess the utilization of immediate surgical services at the time of radiologic intussusception reduction. All radiologic intussusception reductions at a tertiary care children's hospital from November 2007 through August 2012 were reviewed to determine method, complications, clinical status of the child, and time between unsuccessful reduction and operative intervention. Among 433 patients with intussusception referred for fluoroscopic reduction, 86.1% (n = 373) had successful reductions, and 13.9% (n = 60) had unsuccessful reductions. Five perforations represented 8.3% (5/60) of the unsuccessful and 1.2% (5/433) of the total reduction attempts. Six patients' conditions became hemodynamically unstable during attempted reduction (four perforations, two unsuccessful reductions without perforation), representing 10% (6/60) of unsuccessful and 1.4% (6/433) of total reduction attempts. Percutaneous needle decompression and cardiopulmonary resuscitation restored hemodynamic stability in all cases. The mean time to surgery after perforation was 1.3 hours, after unsuccessful reduction complicated by hemodynamic instability was 2.2 hours, and after unsuccessful radiologic reduction without complication was 4.3 hours. In this series, complications requiring immediate medical or surgical attention were rare, occurring in 1.6% of cases (five bowel perforations, two cases of hemodynamic instability without perforation). On-site surgeon presence may not be necessary at the time of radiologically guided reduction attempts provided that the attending physician is facile with percutaneous needle decompression and management of hemodynamic instability and that ultimate surgical care can be arranged expeditiously.

Deep sedation during pneumatic reduction of intussusception

Pneumatic reduction of intussusception under fluoroscopic guidance is a routine procedure. The unsedated child may resist the procedure, which may lengthen its duration and increase the radiation dose. We use deep sedation during the procedure to overcome these difficulties. The purpose of this study was to summarize our experience with deep sedation during fluoroscopic reduction of intussusception and assess the added value and complication rate of deep sedation. All children with intussusception who underwent pneumatic reduction in our hospital between January 2004 and June 2011 were included in this retrospective study. Anesthetists sedated the children using propofol. The fluoroscopic studies, ultrasound (US) studies and the childrens' charts were reviewed. One hundred thirty-one attempted reductions were performed in 119 children, of which 121 (92%) were successful and 10 (8%) failed. Two perforations (1.5%) occurred during attempted reduction. Average fluoroscopic time was 1.5 minutes. No complication to sedation was recorded. Deep sedation with propofol did not add any complication to the pneumatic reduction. The fluoroscopic time was short. The success rate of reduction was high,raising the possibility that sedation is beneficial, possibly by smooth muscle relaxation.

Experience of fluoroscopic reduction of isolated zygomatic arch fractures using a C-arm imaging system

Experience of fluoroscopic reduction of isolated zygomatic arch fractures using a C-arm imaging system

Direct Visualization for Syndesmotic Stabilization of Ankle Fractures

Ankle fractures with syndesmotic injury treated via standard trans-syndesmotic fixation have a high percentage of syndesmotic malreduction.(10) We established a protocol involving both direct syndesmosis visualization and meticulous tibial incisura reconstruction via the posterior malleolus fracture fragment, when present, via the attached, intact PITFL, then compared this with historic controls to assess improvement after this type of syndesmosis reconstruction. One hundred forty-nine consecutive direct visualization patients were treated prospectively with either open posterior malleolus reduction and fixation, regardless of fragment size ("PM'': 38 patients), or, with no posterior malleolar fracture, open fixation with locked syndesmotic screws ("S'': 97 patients); fracture-dislocations combined both fixation types ("C'': 16 patients). The syndesmosis was opened and debrided in all. All patients had preoperative MRI and postoperative CT. Distances between the fibula and anterior and posterior incisura facets were measured on axial CT. An incongruent joint was defined as an A-P difference greater than 2 mm. Our historic controls were 25 patients previously fixed via indirect, fluoroscopic reduction and syndesmotic screws. In the direct visualization group, 24 ankles (16%) had incongruity, compared with 13 controls (52%). The average difference between anterior and posterior colliculi measurements between PM and C was significant (p = 0.017). Malreductions were significantly decreased in the direct visualization group. However, our reduction sometimes remains imprecise, even with direct visualization and attention to detail. Also, posterior malleolar reconstruction was more accurate than syndesmotic screw fixation in our study.

Arthroscopic Assessment of Intra-Articular Distal Radius Fractures After Open Reduction and Internal Fixation From a Volar Approach

The volar approach with locked plating is a common treatment for intra-articular distal radius fractures. The purpose of this study was to arthroscopically assess the articular surface after internal fixation through the volar approach as a means to evaluate the ability of an extra-articular reduction to anatomically restore the joint surface. Sixteen patients with intra-articular distal radius fractures were prospectively enrolled. A volar approach and internal fixation using a locked volar plate was performed. Using a visual analog scale (VAS), the fracture reduction was clinically graded on the quality of reduction of the visible metaphyseal fracture lines, fluoroscopically graded, and arthroscopic graded. Maximum step and gap deformity were recorded from arthroscopy and plain radiograph. The mean VAS score for the fracture reduction based on extra-articular fracture lines was 7.4. The mean VAS score for the fluoroscopic reduction was 8.2. The mean VAS score for the arthroscopic reduction was 6.4. The arthroscopic VAS score was significantly lower than the VAS score for fluoroscopy but was not significantly different than the VAS score for metaphyseal reduction. Mean arthroscopic measurement of maximum step and gap deformity were 1 mm and 2 mm, respectively. Mean postoperative radiographic maximum step and gap deformity were both less than 1 mm. The arthroscopic step and gap deformities were significantly greater than the radiographic deformities. A volar approach, indirect reduction, and locked plate fixation is a useful technique in restoring articular congruity after distal radius fracture. The number of fracture lines and presence of step and gap deformity can be adequately assessed using clinical and fluoroscopic assessment. However, the magnitude of step and gap deformity may be underestimated.

Arthroscopic Reduction and Percutaneous Fixation of Scaphoid Fracture and Nonunion

Purpose: To analyze the results of an arthroscopic reduction and percutaneous fixation of scaphoid fracture and nonunion. Materials and Methods: Fourteen scaphoid fractures or nonunion patients were analyzed clinically. There were 13 men and 1 woman, with a mean age of 30 (14-45) years. The average follow-up time was 13 months (12-18). Three cases had delayed union, 5 cases had nonunion and 6 cases had a fracture. After fluoroscopic reduction and an arthroscopic examination, the scaphoid was fixed with an Acutrak screw or K-wire percutaneously. The serial radiographs were checked by 2 weeks to confirm the bony union. The Mayo wrist score and DASH were used to assess the functional result at the final follow up. Results: Bony union was acquired in 13 cases in a mean time of 8 weeks. The mean Mayo wrist score was 86 points (60-100) with 7 excellent, 4 good, 2 fair and 1 poor case. The mean DASH was 11.1 points (0-63.3). Conclusion: In scaphoid fracture and delayed union, good results could be obtained by an arthroscopic reduction and percutaneous fixation. However, in scaphoid nonunion, this technique should only be used in selected cases.

Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fractures

Purpose Although arthroscopy offers an unparalleled view of intra-articular pathology, its use in the treatment of intra-articular distal radius fractures remains controversial. This study was designed to compare functional and radiologic outcomes of arthroscopically assisted (AA) versus fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures. Type of study Retrospective, case-matched comparison of 2 different procedures. Methods Between January 1995 and December 1999, 15 patients with comminuted intra-articular distal radius fractures underwent AA external fixation and percutaneous pinning. Fifteen patients underwent external fixation and FA reduction and pinning. Patients in both groups were matched for fracture pattern and age. Results Follow-up evaluation consisted of an evaluation of grip strength and range of motion as well as radiographic evaluation of palmar tilt, radial shortening, stepoff, and degenerative changes. Health-related quality of life outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Patients who underwent AA surgery had significantly improved supination compared with those who underwent FA surgery (88° v 73°; P = .02). AA reduction also resulted in improved wrist extension (mean, 77° v 69°; P = .01) and wrist flexion (mean, 78° v 59°; P = .02). Radial shortening, Knirk and Jupiter congruity grades, and DASH scores were similar for both groups. Conclusions AA reduction and fixation of intra-articular distal radius fractures permits a more thorough inspection of the ulnar-sided components of the injury. At follow-up evaluation, patients who underwent AA procedures had a greater degree of supination, flexion, and extension than patients undergoing FA surgery. Level of evidence Level II prospective cohort study.

Fluoroscopic dose reduction using a digital television noise-reduction device.

A digital video image processor, connected to a video system in a conventional pediatric fluoroscopy room, was used to determine whether the device could provide satisfactory fluoroscopic images during routine examinations when the x-ray tube was operated at substantially lower than normal radiation-dose levels. A 50% reduction resulted in image quality which was indistinguishable from conventional fluoroscopic views.

Radiation hazards to nonradiologists participating in x-ray examinations.

• Injuries to physicians continue to occur because of the increasing use of x-rays and gamma radiation in modern diagnosis. The danger to nonradiologists is especially great until they learn to practice safety habits and to use available protective equipment. The survey here reported revealed poor safety habits in most nonradiological personnel and resulted in striking improvement. In the past, fluoroscopic reduction of fractures was the commonest cause of injury. Highly malignant forms of carcinoma developed in the skin, but damage to the hematopoietic and reproductive organs has also been serious. New procedures such as cystourethrography, angiography, myelography, and hip-nailing are here analyzed as to the amount of exposure involved, and the methods needed for protection are described.