Fluoroscopy Research Articles

Analysis of stress response distribution in patients with lateral ankle ligament injuries: a study of neural control strategies utilizing predictive computing models.

Ankle sprains are prevalent in sports, often causing complex injuries to the lateral ligaments. Among these, anterior talofibular ligament (ATFL) injuries constitute 85%, and calcaneofibular ligament (CFL) injuries comprise 35%. Despite conservative treatment, some ankle sprain patients develop chronic lateral ankle instability (CLAI). Thus, this study aimed to investigate stress response and neural control alterations during landing in lateral ankle ligament injury patients. This study recruited twenty individuals from a Healthy group and twenty CLAI patients performed a landing task using relevant instruments to collect biomechanical data. The study constructed a finite element (FE) foot model to examine stress responses in the presence of laxity of the lateral ankle ligaments. The lateral ankle ligament was modeled as a hyperelastic composite structure with a refined representation of collagen bundles and ligament laxity was simulated by adjusting material parameters. Finally, the validity of the finite element model is verified by a high-speed dual fluoroscopic imaging system (DFIS). CLAI patients exhibited earlier Vastus medialis (p < 0.001) and tibialis anterior (p < 0.001) muscle activation during landing. The FE analysis revealed that with laxity in the ATFL, the peak von Mises stress in the fifth metatarsal was 20.74MPa, while with laxity in the CFL, it was 17.52MPa. However, when both ligaments were relaxed simultaneously, the peak von Mises stress surged to 21.93MPa. When the ATFL exhibits laxity, the CFL is subjected to a higher stress of 3.84MPa. Conversely, when the CFL displays laxity, the ATFL experiences a peak von Mises stress of 2.34MPa. This study found that changes in the laxity of the ATFL and the CFL are linked to shifts in metatarsal stress levels, potentially affecting ankle joint stability. These alterations may contribute to the progression towards CLAI in individuals with posterolateral ankle ligament injuries. Additionally, significant muscle activation pattern changes were observed in CLAI patients, suggesting altered neural control strategies post-ankle ligament injury.

A novel simplified sonographic approach with fluoroscopy-controlled L5 transforaminal epidural injections in patients with high iliac crest: a retrospective study

BackgroundTo explore a novel ultrasound (US) modality for lumbar transforaminal epidural injections (TFEIs) in patients with low back pain (LBP) and L5 radicular pain combined with high iliac crest (HIC).MethodsOne-hundred and forty-one patients were retrospectively stratified into two groups based on the treatment they received: novel group, receiving US-guided and fluoroscopy (FL)-controlled TFEIs using a sagittal oblique approach between the superior articular process of L5 and S1, and control group, receiving US-guided TFEIs with conventional transverse approach combined with FL confirmation. Accuracy of contrast dispersing into lumbar epidural space was set as the primary endpoint. Radiation dosages, procedure time, numeric rating scale (NRS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, adverse events, and rescue analgesic requirement were also recorded. The generalized liner mixed model (GLMMs) was employed to compare the repeatedly measured variables between groups, taking individual confounding factors as covariance.ResultsThe accuracy of TFEIs was 92.8% and 65.2% in novel and control group, with a significant difference of 26.7% (95% CI: 15.4%, 39.8%) between two modalities (p < 0.001). Significant pain relief was observed in novel group as opposed to control group after one injection. Procedure time in novel group (8.4 ± 1.6 min) was shorter than control group (15.8 ± 3.5 min) (p < 0.001) with less radiation dosage (3047 ± 5670 vs. 8808 ± 1039 μGy/m2, p < 0.001). Significantly, lower incidence of L5 paresthesia occurred in novel group. Statistical differences of NRS scores between the novel and control group were reached at 1 week after procedure (1 (IQR: − 1–3) vs. 3 (IQR: − 1–7), p = 0.006), while not reached at both 1- (1 (IQR: 0–2) vs. 1 (IQR: − 1–3), p = 0.086) or 3-month follow-up (0 (IQR: − 1–1) vs. 1 (IQR: 0–2), p = 0.094). Both groups showed similar functional improvement (F = 0.103, p = 0.749) during follow-up.ConclusionsThe novel sonographic technique provided superior accuracy needle placement and better pain-relieving effect through one injection as compared to the routine transverse approach. Consequently, in situations where the HIC imposed limitations for TFEIs performance on L5, the novel technique should be recommended to consider increasing accurate puncture, minimizing radiation exposure, consuming procedure time, and reducing the risk of neuraxial injury.

Fluoroscopy-only guided transcatheter patent foramen ovale closure: the importance of pre-procedural echocardiography.

Percutaneous closure of a patent foramen ovale (PFO) to prevent recurrent paradoxical thromboembolic events has become the standard of care. However, it remains uncertain if transesophageal echocardiography (TOE) guidance improves procedural success with an existing comprehensive pre-procedural TOE. The aim of the study was to compare the effectiveness of percutaneous PFO closure guided by fluoroscopy (FS) only vs TOE plus FS. Consecutive patients undergoing percutaneous PFO closure between February 2017 and April 2023 were analyzed. Based on pre-procedural echocardiography, patients were scheduled either for an FS-only or TOE/FS-guided procedure. The primary-endpoint was effective PFO-closure (residual-shunt grade 0/1 at 6-month follow-up). The secondary-endpoints included procedural safety/efficacy and major adverse cardiovascular events during hospital stay and at the 6-month follow-up. Two hundred-three patients (mean age 51.8 ± 12.5 years, 39.4% women, Risk of Paradoxical Embolism score = 7 [IQR = 6-7]) underwent PFO closure with FS-only guidance (88 patients, 43.3%) or TOE/FS guidance (115 patients, 56.7%). The main indications for PFO closure were cryptogenic stroke (179 patients, 88.2%) and peripheral embolism (13 patients, 6.4%). At baseline, a right-to-left shunt of grade 2 or higher was present in 199 patients (98%). The procedure time in the FS group was shorter (13 minutes in the FS group vs 16.5 minutes in the TOE/FS group, P = .002). The immediate procedural success was 99.5%. At 6 months, effective closure was achieved in 195 patients (96.1% [FS group: 97.7% vs TOE/FS group 97.8%, P = .29]). The rates of atrial fibrillation and recurrent thromboembolic events were not different among the procedural strategies (3.9% [P = .47] and 0.5% [P = .43]). After comprehensive pre-procedural echocardiography workup, PFO closure with FS guidance only seems equally safe and effective as TOE/FS guidance. A standardized pre-procedural echocardiography protocol facilitates procedural planning with excellent echocardiographic and clinical outcomes.

Critical Examination of Methods to Determine Tibiofemoral Kinematics and Tibial Contact Kinematics Based on Analysis of Fluoroscopic Images.

Goals of knee replacement surgery are to restore function and maximize implant longevity. To determine how well these goals are satisfied, tibial femoral kinematics and tibial contact kinematics are of interest. Tibiofemoral kinematics, which characterize function, is movement between the tibia and femur whereas tibial contact kinematics, which is relevant to implant wear, is movement of the location of contact by the femoral implant on the tibial articular surface. The purposes of this review article are to describe and critique relevant methods to guide correct implementation. For tibiofemoral kinematics, methods are categorized as those which determine (1) relative planar motions and (2) relative three-dimensional (3D) motions. Planar motions are determined by first finding anterior-posterior (A-P) positions of each femoral condyle relative to the tibia and tracking these positions during flexion. Of the lowest point (LP) and flexion facet center (FFC) methods, which are common, the lowest point method is preferred and the reasoning is explained. 3D motions are determined using the joint coordinate system (JCS) of Grood and Suntay. Previous applications of this JCS have resulted in motions which are largely in error due to "kinematic crosstalk." Requirements for minimizing kinematic crosstalk are outlined followed by an example, which demonstrates the method for identifying a JCS that minimizes kinematic crosstalk. Although kinematic crosstalk can be minimized, the need for a JCS to determine 3D motions is questionable based on anatomical constraints, which limit varus-valgus rotation and compression-distraction translation. Methods for analyzing tibial contact kinematics are summarized and validation of methods discussed.

Single versus double percutaneous pinning of pediatric distal radius fractures.

The aim of this study was to compare early clinical and radiographic results of single- versus double-pin fixation of unstable pediatric distal radius fractures. A total of 103 consecutive closed distal radius fractures treated with either single or double percutaneous pinning at a tertiary level I pediatric hospital were analyzed. All patients had open physes and had fractures that failed initial closed reduction and casting. Postoperative fracture displacement was assessed by measuring the difference in angulation of the radius in the anteroposterior and lateral views from intraoperative fluoroscopic images to postoperative radiographs taken on the day of pin removal. Complications were identified from the medical record review. In 103 operative distal radius fractures in 101 patients (70 males, 31 females), 52 and 51 distal radius fractures were treated with single and double pinning, respectively. The median [interquartile range (IQR)] age at the time of surgery was 12.1 (9.0-14.0) years, with the single-pinning group being younger by 1.9 years (P < 0.01). Median (IQR) postoperative angulation in the anteroposterior radiograph (coronal plane) was 2° (1-7°) with one pin versus 1° (0-2°) with two pins (P < 0.01). Median (IQR) postoperative angulation in the lateral radiograph (sagittal plane) was 3° (1-10°) with one pin versus 1° (0-2°) with two pins (P < 0.01). There were no significant differences in complications between the single- and double-pinning groups. Double-pin fixation resulted in a statistically significant, but clinically negligible, reduction in postoperative fracture displacement compared with single-pin fixation. Complication rates were similar in both groups. These findings suggest that either single- or double-pinning techniques can be effective, provided appropriate reduction and postoperative immobilization are achieved.

Influence of anatomical structure on antiscatter grid performance in 2D: application to x-ray angiography and a prototype 29:1 ratio grid

Objective. The use of uniform phantoms to assess the influence of x-ray scatter and antiscatter grids on x-ray angiography and fluoroscopy image quality disregards the influence of spatially variable x-ray attenuation of patients. The purpose of this work was to measure scatter to primary ratio (SPR) and antiscatter grid SNR improvement factor (K SNR) using experimental conditions which better mimic patient imaging conditions. Approach. Three adult-sized anthropomorphic phantoms were used. AP and lateral projection images of the thorax and abdomen were acquired with and without an antiscatter grid. Grids with ratio 15:1 and 29:1 (r15, r29) and x-ray fields of view 20, 25 (thorax) and 32, 42 cm (abdomen) were tested. Combined with a-priori measurements of grid scatter and primary transmission fractions, these images were used to calculate 2D SPR and K SNR maps. Main results. Results demonstrated that measurements by uniform phantom do not describe the complex 2D SPR and K SNR distributions associated with anthropomorphic phantoms. The regions of the images with the lowest primary x-ray intensity (greatest attenuation) had the highest SPR and the highest K SNR attributable to the grids. Considering all conditions, the 95th percentile of the SPR maps was in the range 42%–185% greater than the median values and that of the K SNR maps was 4%–20% higher than the median values. The combined influences of SID 120 vs. 107 cm and r29 vs. r15 grid resulted in K SNR in the range 1.05–1.49. Significance. Performance of anti-scatter grids using anatomically complex phantoms highlights the substantial variation of SPR and K SNR within 2D images. Also, this work demonstrates the benefit of the prototype r29 grid for thoracic and abdominal angiography imaging conditions is substantial, especially for large patients and radiodense image regions.

LV cathode position in CRT recipients: How can we benefit from CMR?

BackgroundLeft ventricular lead positioning represents a key step in CRT optimization. However, evidence for its guidance based on specific topographical factors and related imaging techniques is sparse. ObjectiveTo analyze reverse remodeling (RR) and clinical events in CRT recipients based on LV cathode (LVC) position relative to latest mechanical activation (LMA) and scar as determined by cardiac magnetic resonance (CMR). MethodsThis is a retrospective single-center study of 68 consecutive Q-LV-guided CRT-D and CRT-P recipients. Through CMR-based 3D reconstructions overlayed on fluoroscopy images, LVCs were stratified as concordant, adjacent, or discordant to LMA (3 segments with latest and greatest radial strain) and scar (segments with >50% scar transmurality). The primary endpoint of RR (expressed as percentage ESV change) and secondary composite endpoint of HF hospitalizations, LVAD/heart transplant, or cardiovascular death were compared across categories. ResultsLVC proximity to LMA was associated with a progressive increase in RR (percentage ESV change: concordant −47.0 ± 5.9%, adjacent −31.4 ± 3.1%, discordant +0.4 ± 3.7%), while proximity to scar was associated with sharply decreasing RR (concordant +10.7 ± 12.9%, adjacent +0.3 ± 5.3%, discordant −31.3 ± 4.4%, no scar −35.4 ± 4.8%). 4 integrated classes of LVC position demonstrated a significant positive RR gradient the more optimal the category (class I -47.0 ± 5.9%, class II -34.9 ± 2.8%, class III -5.5 ± 4.3%, class IV + 3.4 ± 5.2%). Freedom from composite secondary endpoint of HF hospitalization, LVAD/heart transplant, or cardiovascular death confirmed these trends demonstrating significant differences across both integrated as well as individual LMA and scar categories. ConclusionIntegrated CMR-determined LVC position relative to LMA and scar stratifies response to CRT.

Ultrasound-Guided Cervical Selective Nerve Root Block versus Fluoroscopy-Guided Interlaminar Epidural Injection for Cervical Radicular Pain: A Randomized, Prospective, Controlled Study.

Ultrasound (US)-guided cervical selective nerve root block (CSNRB) procedures are increasingly being performed as an alternative to conventional fluoroscopy (FL)-guided epidural injections for the treatment of cervical radicular pain. The aim of this study was to compare the effectiveness of US-guided CSNRB versus FL-guided interlaminar cervical epidural steroid injection (IL-CESI) for cervical radicular pain. A total of 60 patients with cervical radicular pain due to a single-level disc herniation were randomized into either the FL or US group. The numeric rating scale, Short Form-36, and neck disability index were evaluated before treatment at months 1, 3, and 6 after treatment. Procedure time, complications, pain medication consumption, and patient satisfaction were also recorded. Patients experienced significant improvement in pain, disability, and quality of life scores up to 6 months after the procedure (p < 0.001). Treatment success rate was achieved in 56.6% of the IL-CESI group and 50% of the CSNRB group without any significant difference between the study arms (p = 0.617). US-guided CSNRB was shown to be as effective as the FL-guided IL-CESI in the treatment of cervical radicular pain, in addition to the absence of radiation exposure and requiring less procedure time.

Fundus-to-Antrum Ratio Measured with Fluoroscopy within One Week after Endoscopic Sleeve Gastroplasty Predicts Total Body Weight Loss over Time.

Background and Aims: Endoscopic sleeve gastroplasty (ESG) is a minimally invasive bariatric procedure to induce weight loss through restrictive physiology. This study was designed to evaluate the fluoroscopic measurement of gastric dimensions after ESG as a predictor of Total Body Weight Loss (TBWL) over time. Methods: Post-ESG patients were enrolled prospectively between August 2013 and August 2019. An upper gastrointestinal (GI) fluoroscopy was obtained within 7 days after the procedure. Two blinded, independent radiologists reviewed fluoroscopic images and measured the gastric lumen transverse diameter in three separate areas of the fundus, body, and antrum. The primary outcome was achieving a TBWL of ten percent or more after ESG. Results: In total, 162 patients were included in the analysis (65% female) and had a mean body mass index (BMI) of 39 ± 6 at baseline. Patients had a mean maximum TBWL of 16.5 ± 8.3%. Respectively, 92%, 75%, and 50% of patients achieved a TBWL of 5%, 10%, or 15% or more. The mean post-procedural UGI gastric fundus/antrum transverse measurement ratio was 1.2 ± 0.6. A higher fundus-to-antrum ratio was significantly associated with a TBWL of 10% or more during follow-up in the multivariable model (OR 2.49, 95% CI 1.31-4.71; p-value 0.005). The prediction score based on the fundus-to-antrum ratio hd an area under the ROC curve of 0.79 (95% CI 0.75-0.83) for predicting a TBWL of 10% or more during follow-up. Conclusions: Measuring gastric the fundus/antrum ratio within one week of endoscopic sleeve gastroplasty (ESG) is a consistent and independent predictive measure of sustained TBWL during long-term follow-up.

Study of urologic exposure dose in selective organ's cell & behavior of Wistar rats

BackgroundRadiologic fluoroscopy procedures have been imposing considerable exposure dose to staff with serious consequences relative to dose quantity which is still continuing as challenge of studies, hence the aims were to assess the animal behavior, quantify blood components and red blood cells morphology after exposure to x-ray urologic fluoroscopy doses (0.3, 0.8, 1.8 and 2.5 mSv). Methodsurologic exposure doses measured by TLDs chips and TLD reader Model 5500 from selected hospitals. These doses used to expose Wister male rats weighted (275 ± 2.0 g). The collected data were animal behavior, quantity of blood components and cellular changes in RBCs, kidneys, liver & testicles then analyzed by SPSS- 20 (SPSS Inc., Chicago, IL, USA) Resultsshowed that a dose of 2.5 mSv decreased significantly (p value = 0.00) the motor activity of rats. and the blood components decreased as follows: WBC (30.2%), Lymphocytes (40%.0), Neutrophils (35.7%), RBC (37.9%), MCV (32.2%) and RCDW (31.5%). At exposure dose of 0.3 mSv a mild morphological changes as circular shape deformity and loss of bi-concavity of RBCs. At 0.8 mSv RBCs diameter increment (10 ± 0.4 μm) and formation of spikes. At 1.8 mSv RBC underwent anisocytosis and poikilocytosis. While at 2.5 mSv the RBC showed intensive spikes, clustering and some underwent hemolysis. Morphological changes were induced also, at 2.5 mSv for the followings: The renal cortex showed bleeding & congestion at 2.5 mSv. The Renal medulla showed bleeding at 2.5 mSv. The liver texture showed bleeding and congestion with two nuclei- Kupffer cells hyperplasia, ballooning of hepatocytes with Acidophilic bodies at 2.5 mSv. the testicles tissues developed congestion and bleeding. Conclusionfluoroscopic urologic exposure dose can induce significant behavioral, RBCs changes and reduction in blood components.

Poster 187: Describing the Contribution of the Vacuum Effect and Hip Capsule in Restraint to Axial Traction in Patients Undergoing Hip Arthroscopy

Objectives: In recent investigations, there has been increased focus on hip laxity and hip capsular instability, particularly in the setting of hip arthroscopy. The capsule and its internal negative pressure effects have been shown to be major contributors to hip joint stability, however, the relative contributory role of these elements remains unknown. Intraoperatively, improved understanding of hip capsule biomechanics is imperative for optimization of arthroscopic technique to access the central compartment with minimal soft tissue trauma. In turn, this can help reduce the risk of hip instability and maximize patient outcomes. The purpose of this study was to define the stiffness coefficient of the hip capsule and vacuum phenomenon in response to hip axial traction. Our hypothesis was that the vacuum phenomenon would have a greater relative contribution to axial distraction stiffness at mid-range distraction, and that the hip capsule stiffness coefficient would be greater at terminal distraction. Methods: A review of a prospectively collected database of patients undergoing hip arthroscopy was conducted from 1 July 2021 to 31 June 2022. Patients in this database underwent hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS). Inclusion criteria were 1) completion of the study traction protocol and 2) completion of hip joint venting prior to capsulotomy. Exclusion criteria were 1) previous hip surgery and 2) lack of hip distraction at 50 pounds of axial traction. The study traction protocol involved applying axial traction prior to instrumentation (Native State) of the hip using a post-free distraction system. Hips were then vented using a spinal needle and the traction protocol was repeated (Vented State). Traction intervals were 0, 50, and 100 lbs of force. Fluoroscopic images were taken at each traction interval and standardized to preoperative radiographs, which allowed for a calculation of the lateral joint space width at each interval. Overall distraction distance was calculated as the difference between 0 lbs traction and 50 and 100 lbs traction. The stiffness coefficient was calculated as k = traction force interval/distraction distance in both the Native and Vented States. Comparisons using paired-samples t-tests were conducted between the stiffness coefficients of the Native State and Vented State at 50 lbs and at 100 lbs. A p-value of &lt;0.05 was utilized to indicate statistical significance. Results: Twenty-one patients were identified who met inclusion criteria. Mean age was 34.4 ± 13.4 years with 100% female and a mean BMI of 24.2 ± 4.8 points. Mean stiffness coefficient at 50 lbs in the Native State (10.9 ± 3.3) was significantly higher than the Vented State (4.9 ± 0.7, p &lt; 0.001), with similar findings at 100 lbs in the Native State (10.1 ± 1.7) and Vented State (8.7 ± 1.3, p &lt; 0.001). In the Vented State, the stiffness coefficient was significantly greater at 100 lbs (8.7 ± 1.3) than at 50 lbs (4.9 ± 0.7, p &lt; 0.001). Conclusions: Our results provide an objective characterization of the individual contributions of the hip soft tissue restraints and the vacuum phenomenon to hip resistance to axial traction. At 50 pounds of traction, the vacuum effect contributes to ~55% of the axial distraction stiffness (resistance to axial distraction). At 100 pounds of traction force, the vacuum effect contributes only ~14% of the axial distraction stiffness. The resistance of the hip to axial distraction is of substantial clinical significance as minimization of traction force decreases intraoperative soft tissue trauma. This, however, needs to be balanced with obtaining sufficient working space within the hip joint. There is still substantial controversy regarding the biomechanics of the hip and the optimal methods for minimizing traction force related injury (e.g., post-less traction, minimization of traction time, air arthrogram, and joint venting). These data demonstrate that soft tissues have a proportionally greater effect on restraint of the of the hip at terminal distraction (~1 cm distraction), whereas the vacuum effect has a greater influence on mid-range distraction (~0.5 cm distraction). The proposed model for this phenomenon is that the negative pressure and the soft tissue tension work in parallel to restrain the hip joint. The increased influence of the soft tissue tension at end-range distraction may be due to a check rein effect of the soft tissues; once the iliofemoral ligament has been tensioned to its maximum length its stiffness and capacity for transfer of tensile force increases rapidly. In conclusion, at 50 pounds of traction, the vacuum effect contributes to ~55% of the axial distraction stiffness (resistance to axial distraction). At 100 pounds of traction force, the vacuum effect contributes only ~14% of the axial distraction stiffness. These results demonstrate that the vacuum effect is a significant restraint to axial traction applied across the hip at mid-range distraction. Additionally, the hip capsule has a relatively greater contribution to terminal distraction stiffness.

Poster 238: Accuracy, Safety, and Cost of Patient-Specific Cutting Guides for Alignment-Correcting Osteotomy

Objectives: The purpose of this study was to determine the cost, accuracy of radiographic correction, and safety with respect to complication rates and fluoroscopic usage in patient-specific cutting guides (PSCG) osteotomies compared to an age- and body mass index (BMI)-matched group of controls using standard cutting guides (SCG). Methods: Patients were retrospectively reviewed between 2017 and 2022 at a single urban academic institution. Patients undergoing high tibial osteotomy (HTO) or distal femoral osteotomy (DFO) with PSCG (Bodycad 3d, Quebec, Canada) were identified. Traditional osteotomies were selected for the SCG group using propensity matching based on age, sex, BMI, osteotomy type. All procedures were performed by 1 of 2 fellowship-trained sports orthopaedic surgeons. Procedure time, fluoroscopy time, tourniquet time, and concomitant procedures were extracted from operative notes. Blinded, 2-reader hip-knee-ankle (HKA), posterior tibial slope (PTS) and mechanical axis deviation (MAD) measurements were performed on pre- and postoperative weightbearing radiographs for each procedure. Intraclass correlation coefficients (ICCs) were calculated to determine the reliability between the intended intraoperative correction of HKA and/or PTS the measured result on postoperative radiographs. A time-driven activity-based costing (TDABC) analysis was performed to compare costs of PSCG versus SCG. Results: Forty-two patients were included in the final analysis. Each group was 47.6% female, with 11 HTOs and 10 DFOs performed in each group. Final HKA (2.7° vs 1.9°, p = 0.355), PTS (1.6° vs 2.6°, p = 0.794) and MAD (10.2 vs 5.8 mm, p = 0.214) did not significantly differ between SCG and PSCG groups (MAD seems higher for SCG. The ICC between the intended and measured HKA correction was 0.841 (good) in the PSCG group and 0.623 (moderate) in the SCG group. PSCG osteotomies averaged 18.5 minutes less (p = 0.392) and required 16.7 minutes less tourniquet time (p = 0.121). Fluoroscopy time was significantly lower in the PSCG group compared to SCG (99 vs 43 seconds, p &lt; 0.001), as well as radiation dose (7.8 vs 2.9 mGy, p = 0.013). TDABC analysis demonstrated a base cost of $21,067 for PSCG and $23,896 for SCG. When the cost of the cutting guide and pre-operative imaging were included, PSCG was $2,829 more expensive than SCG. There was a lower, though non-statistically significant, rate of hinge fractures (9.5% vs 33.3%, p = 0.130) and return to the OR (4.8% vs 19.0%, p = 0.343) when comparing PSCG and SCG groups. Conclusions: Both traditionally guided osteotomies and PSCG-guided osteotomies accurately corrected lower extremity malalignment. Utilization of PSCG resulted in similar procedure times and cost. PSCG required less fluoroscopy and resulted in less radiation to conventional osteotomy and trended toward a decreased rate of postoperative complications.

The Utility and Feasibility of Smart Glasses in Spine Surgery: Minimizing Radiation Exposure During Percutaneous Pedicle Screw Insertion.

Spine surgeons are often at risk of radiation exposure due to intraoperative fluoroscopy, leading to health concerns such as carcinogenesis. This is due to the increasing use of percutaneous pedicle screw (PPS) in spinal surgeries, resulting from the widespread adoption of minimally invasive spine stabilization. This study aimed to elucidate the effectiveness of smart glasses (SG) in PPS insertion under fluoroscopy. SG were used as an alternative screen for fluoroscopic images. Operators A (2-year experience in spine surgery) and B (9-year experience) inserted the PPS into the bilateral L1-5 pedicles of the lumbar model bone under fluoroscopic guidance, repeating this procedure twice with and without SG (groups SG and N-SG, respectively). Each vertebral body's insertion time, radiation dose, and radiation exposure time were measured, and the deviation in screw trajectories was evaluated. The groups SG and N-SG showed no significant difference in insertion time for the overall procedure and each operator. However, group SG had a significantly shorter radiation exposure time than group N-SG for the overall procedure (109.1 ± 43.5 seconds vs. 150.9 ± 38.7 seconds; p = 0.003) and operator A (100.0 ± 29.0 seconds vs. 157.9 ± 42.8 seconds; p = 0.003). The radiation dose was also significantly lower in group SG than in group N-SG for the overall procedure (1.3 ± 0.6 mGy vs. 1.7 ± 0.5 mGy; p = 0.023) and operator A (1.2 ± 0.4 mGy vs. 1.8 ± 0.5 mGy; p = 0.013). The 2 groups showed no significant difference in screw deviation. The application of SG in fluoroscopic imaging for PPS insertion holds potential as a useful method for reducing radiation exposure.

Clinical Applications for Spread of Excitation Functions Obtained Via Electrically Evoked Compound Action Potentials (eCAP).

To assess the clinical utility of spread of excitation (SOE) functions obtained via electrically evoked compound action potentials (eCAP) to 1) identify electrode array tip fold-over, 2) predict electrode placement factors confirmed via postoperative computed tomography (CT) imaging, and 3) predict postoperative speech recognition through the first year post-activation in a large clinical sample. Retrospective case review. Cochlear implant (CI) program at a tertiary medical center. Two hundred seventy-two ears (238 patients) with Cochlear Ltd. CIs (mean age = 46 yr, range = 9 mo-93 yr, 50% female) implanted between August 2014 and December 2022 were included. eCAP SOE widths (mm) (probe electrodes 5, 11, and 17), incidence of electrode tip fold-over, CT imaging data (electrode-to-modiolus distance, angular insertion depth, scalar location), and speech recognition outcomes (consonant-nucleus-consonant [CNC], AzBio quiet, and +5 dB SNR) through the first year after CI activation. 1) eCAP SOE demonstrated a sensitivity of 85.7% for identifying tip fold-over instances that were confirmed by CT imaging. In the current dataset, the tip fold-over incidence rate was 3.1% (7 patients), with all instances involving a precurved electrode array. 2) There was a significant positive relationship between eCAP SOE and mean electrode-to-modiolus distance for precurved arrays, and a significant positive relationship between eCAP SOE and angular insertion depth for straight arrays. No relationships between eCAP SOE and scalar location or cochlea diameter were found in this sample. 3) There were no significant relationships between eCAP SOE and speech recognition outcomes for any measure or time point, except for a weak negative correlation between average eCAP SOE widths and CNC word scores at 6 months post-activation for precurved arrays. In the absence of intraoperative CT or fluoroscopic imaging, eCAP SOE is a reasonable alternative method for identifying electrode array tip fold-over and should be routinely measured intraoperatively, especially for precurved electrode arrays with a sheath.

Feasibility study on atrial fibrillation ablation with pulsed field ablation and concomitant occlusion of the left atrial appendage.

Atrial fibrillation (AF) ablation and left atrial appendage occlusion (LAAO) are increasingly performed as individual procedures. Pulsed field ablation (PFA) has significantly reduced procedure duration and may be advantageous for the combined approach. We have launched a programme for simultaneous AF ablation using PFA and LAAO for patients qualifying for both treatments and excluding those with a complex anatomy. We compare procedure duration and fluoroscopy time against individual procedures (either AF ablation or LAAO alone), all performed by the same operators and using consistent technologies. We performed the combined procedure in 10 patients (50% males; median age 70 years) and excluded 2 patients (17%) because of a complex left atrial appendage anatomy. No death, stroke, or major bleeding events, including pericardial effusion, occurred. For single-procedure comparison, 207 AF ablation procedures and 61 LAAO procedures were available. The total median procedure duration was 79 min (range 60-125) for the combined procedure, 71 min (25-241) for individual AF ablation (51 min without and 78 min with 3-dimensional electroanatomic mapping), and 47 min (15-162) for individual LAAO. The respective fluoroscopy times were 21 (15-26), 15 (5-44), and 10 (3-50) min. For the combined procedure, femoral vein access to last PFA application lasted 49 min (34-93) and LAAO added 20 min (15-37). Simultaneous PFA-based AF ablation and LAAO in carefully selected patients is feasible and safe and can be executed within a short overall procedure duration.

GI and GU fluoroscopy in common post-op oncologic surgeries: what you need to know about this leaky business!

Over the past several years, there has been a trend of decreasing screening or diagnostic fluoroscopic examinations ordered by clinical teams, particularly double contrast gastrointestinal studies. The underlying reason is due to increasing number of endoscopic procedures performed by Gastroenterology and Urology and usage of other imaging modalities, which are either more sensitive and/or offer the ability to obtain tissue for confirmation. Many fluoroscopic studies are now tailored toward patients who have undergone gastrointestinal or genitourinary oncologic surgeries, providing both functional and anatomic information, which are important tools for patient management. Some of these surgeries are very complex and an understanding of the postoperative anatomy and potential pitfalls is important to accurately evaluate for complications. The purpose of this article is to describe techniques and indications for common post-operative fluoroscopic procedures in gastrointestinal and genitourinary oncology while reviewing normal appearances. Complications, with emphasis on postoperative leaks, will be highlighted. Familiarity with the various types of gastrointestinal surgeries and urinary diversion techniques and knowledge of the expected postsurgical appearance is essential for achieving an accurate and prompt diagnosis of complications to allow for adequate treatment and management.

Method for defining the horizontal plane in fluoroscopic kinematic analysis

PurposeIn vivo kinematics of skeletal joints and prostheses is affected by gravity; therefore, absolute tilt must be taken into account. However, current fluoroscopic kinematic analysis cannot measure the tilt. This study introduces and validates a method for defining the horizontal plane in fluoroscopy systems to measure the tilt of an object. MethodsA rectangular metal plate (200 ​× ​200 ​× ​10 ​mm) with a flatness of 0.03/100 ​mm was horizontally adjusted using a leveler (sensitivity of 0.02° and accuracy of ±0.06°), and its three-dimensional coordinate was calculated from a two-dimensional fluoroscopic image. A coordinate calculation formula was developed, with precision and accuracy assessed via computer simulations. Actual fluoroscopic tests included four aspects: accuracy under the same condition; accuracy under different X-ray tube height; reproducibility when changing X-ray tube height; and reproducibility when the flat panel was tilted and returned. ResultsThe theoretical measurement error indicated by the computer simulations was 0.0 ​± ​0.2° on the xy-plane and 0.0 ​± ​0.0° on the yz-plane. The actual experimental results showed that the horizontal plane tilt was measured to be −0.2 ​± ​0.1° tilt on the xy-plane and 0.3 ​± ​0.0° tilt on the yz-plane for the device used in this study. The F-test showed no significant differences between the computer simulations and the actual experiments. There were no significant differences between the four actual tests. ConclusionsThis method enables the horizontal plane to be defined and the tilt of an object to be measured in fluoroscopic kinematic analysis.

Use of Yolo Detection for 3D Pose Tracking of Cardiac Catheters Using Bi-Plane Fluoroscopy

The increasing rate of minimally invasive procedures and the growing prevalence of cardiovascular disease have led to a demand for higher-quality guidance systems for catheter tracking. Traditional methods for catheter tracking, such as detection based on single points and applying masking techniques, have been limited in their ability to provide accurate pose information. In this paper, we propose a novel deep learning-based method for catheter tracking and pose detection. Our method uses a Yolov5 bounding box neural network with postprocessing to perform landmark detection in four regions of the catheter: the tip, radio-opaque marker, bend, and entry point. This allows us to track the catheter’s position and orientation in real time, without the need for additional masking or segmentation techniques. We evaluated our method on a dataset of fluoroscopic images from two distinct datasets and achieved state-of-the-art results in terms of accuracy and robustness. Our model was able to detect all four landmark features (tip, marker, bend, and entry) used to generate a pose for a catheter with 0.285 ± 0.143 mm, 0.261 ± 0.138 mm, 0.424 ± 0.361 mm, and 0.235 ± 0.085 mm accuracy. We believe that our method has the potential to significantly improve the accuracy and efficiency of catheter tracking in medical procedures that utilize bi-plane fluoroscopy guidance.

Cardio-respiratory motion compensation for coronary roadmapping in fluoroscopic imaging.

Inferring the shape and position of coronary artery poses challenges when using fluoroscopic image guidance during percutaneous coronary intervention (PCI) procedure. Although angiography enables coronary artery visualization, the use of injected contrast agent raises concerns about radiation exposure and the risk of contrast-induced nephropathy. To address these issues, dynamic coronary roadmapping overlaid on fluoroscopic images can provide coronary visual feedback without contrast injection. This paper proposes a novel cardio-respiratory motion compensation method that utilizes cardiac state synchronization and catheter motion estimation to achieve coronary roadmapping in fluoroscopic images. For more accurate cardiac state synchronization, video frame interpolation is applied to increase the frame rate of the original limited angiographic images, resulting in higher framerate and more adequate roadmaps. The proposed method also incorporates a multi-length cross-correlation based adaptive electrocardiogram (ECG)matching to address irregular cardiac motion situation. Furthermore, a shape-constrained path searching method is proposed to extract catheter structure from both fluoroscopic and angiographic image. Then catheter motion is estimated using a cascaded matching approach with an outlier removal strategy, leading to a final corrected roadmap. Evaluation of the proposed method on clinical x-ray images demonstrates its effectiveness, achieving a 92.8% F1 score for catheter extraction on 589 fluoroscopic and angiographic images. Additionally, the method achieves a 5.6-pixel distance error of the coronary roadmap on 164 intraoperative fluoroscopic images. Overall, the proposed method achieves accurate coronary roadmapping in fluoroscopic images and shows potential to overlay accurate coronary roadmap on fluoroscopic image in assisting PCI.

Immobilization during infant fluoroscopy: Pros and cons

This article explores the practice of immobilization during fluoroscopy procedures for infants, discussing its advantages and disadvantages. The authors examine contrasting policies and thoughts on immobilization across different medical institutions. While some advocate for its routine use to minimize patient motion, enhance imaging quality, and decrease radiation exposure, others question its necessity and raise concerns about patient consent and parental distress. Ethical dilemmas are also discussed regarding patient autonomy and psychological impact on families. The authors advocate for a balanced approach, recognizing the utility of immobilization in certain clinical scenarios while still emphasizing patient-centered care. Ultimately, the article underscores the importance of institutional policies that prioritize both patient safety and ethical principles in pediatric radiology practices.