Fluoroscopy Exposure Research Articles

Pressure-guided evaluation of pulmonary vein occlusion during cryoballoon pulmonary vein isolation for atrial fibrillation compared to contrast-guided approach

Abstract Introduction Single-shot ablation devices (e.g. cryoballoon [CB] technique) have simplified pulmonary vein isolation (PVI) for interventional treatment of atrial fibrillation (AF). Vein occlusion is mainly assessed utilizing contrast media (CM) during CB ablation. However, this approach entails possible risks, including renal impairment and adverse contrast-related allergic reactions. Furthermore, the assessment of pulmonary venography is often challenging and necessitates fluoroscopy exposure. Purpose The primary objective of this study is to compare procedural data and outcome of pressure-guided (PG) vs. conventional (CM) assessment of vein occlusion. Methods and results From 07/2018 to 12/2022, 915 patients with AF (59% paroxysmal) undergoing CB-PVI at our hospital were prospectively enrolled (single-center experience). 369 (40,3%) patients (age 64,5 ± 10 years; 154 females 41,7%) underwent PVI with the use of CM (CM group), while in 546 (59,7%) cases (age 65,3 ± 10 years; 222 females 40,6%) pressure curve assessment (PG group) was exclusively used to guide the procedure (and no contrast was given). Compared with the CM approach, pressure-guided procedures had lower X-ray time (9,5±5min vs 6,4±3,5min, P<0,0001) and X-ray dose (586±546cGy/cm2 vs 96,7±93 cGy/cm2, P<0,0001). Procedure time (PG: 90,3±20,1min, CM: 92,7±22,7 min, p:0,1 ) and ablation time (PG: 1352 ± 365 min, CM: 1393 ± 651 min, p: 0,2) were not different between groups. There was no significant difference observed in the BMI between the two groups, with a mean value of ca. 28.2 ± 4 kg/m2. In 79 redo-procedures, persistent isolation of all pulmonary veins was observed in 11/45 (25%) patients in the CM group and 21/34 (61%) patients in the PG group (p: 0.001). Conclusion Compared to current (CM) assessment of vein occlusion, pressure monitoring is associated with less X-ray exposure during the index procedure and more frequent durable isolation of all PVs during repeat study for recurrence.

External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study

BackgroundSeveral methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur.MethodsWe retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system.ResultsThirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment.ConclusionEF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment.Level of evidenceLevel III.

A clinical comparative study of dual LVIS devices and single flow diversion stenting for the treatment of unruptured V3-V4 vertebral artery dissection.

This study aims to compare the efficacy and safety of using overlapping low-profile visualized intraluminal support (LVIS) devices and flow diversion (FD) for the treatment of unruptured vertebral artery dissection (VAD) in the V3-V4 segments. The clinical and imaging data of 71 patients with unruptured VAD in the V3-V4 segments who underwent either dual LVIS stenting (d-LVIS group) or single FD stenting (FD group) at our center from September 2014 to December 2021 were retrospectively analyzed. Immediate postoperative angiography revealed no significant difference in the degree of occlusion between the two groups in treating vertebral artery dissecting aneurysms (with or without noncompact coiling). However, the d-LVIS group had significantly higher fluoroscopy exposure time and total radiation exposure dose compared to the FD group. During the perioperative period, two cases of pontine infarction and one case of acute thrombosis were encountered. One patient died from subarachnoid hemorrhage during the follow-up period. For dissecting the aneurysm, angiographic follow-up (8.56 ± 1.96 months) showed similar healing outcomes between the two groups (with or without noncompact coiling). However, seven patients (7/40, 17.5%) showed poor healing and one patient showed mild in-stent stenosis. For simple dissection, angiographic follow-up (8.78 ± 1.83 months) showed patent lumens in both groups, with all dissections healing well, and two patients having mild in-stent stenosis. Both methods could effectively treat unruptured VAD in V3-V4 segments. Nevertheless, simple FD implantation is relatively easier to perform and involves lower radiation exposure.

Does prior PCNL affect RIRS? A retrospective analysis of a single center data.

The aim of this study is to investigate the results and safety of retrograde intrarenal surgery (RIRS) in patients who have previously undergone percutaneous nephrolithotomy (PCNL). A retrospective analysis included patients who underwent RIRS for kidney stones between August 2018 and April 2023. Group 1 comprised 396 patients who underwent primary RIRS, while Group 2 included 231 individuals who had RIRS after previous PCNL. Evaluation parameters included preoperative characteristics, stone attributes, operative details, treatment outcomes, stone-free status, and complications. Statistical analysis utilized Student's t test, Mann-Whitney U test, and Pearson Chi-square test (p < 0.05). The mean age, body mass index, stone number, mean stone burden, and SFS were not statistically different between the groups. Lower pole stones were identified in 144 patients in Group 1 and 88 patients in Group 2 (p = 0.315). In Group 1 and Group 2, the mean operation time and fluoroscopy time were 65.23 ± 18.1min, 81.32 ± 14.3min, 26.34 ± 8.31s, 46.61 ± 7.6s, respectively, showing statistically significant differences between the groups (p = 0.013, p < 0.001, respectively). Infundibulum stenosis was identified and treated with a laser in 12% of Group 2 cases. Complications occurred in 12 patients in Group 1 and 14 patients in Group 2 (p = 0.136). A history of PCNL may contribute to extended operation times and increased fluoroscopy exposure in subsequent RIRS without significantly affecting postoperative SFS or complication rates.

Research progress on distal interlocking screws of cephalomedullary nails in intertrochanteric fractures

To summarize the new research progress in distal interlocking screws of cephalomedullary nails for the treatment of intertrochanteric fractures. Relevant domestic and foreign literature was extensively reviewed to summarize the static/dynamic types of distal interlocking screw holes, biomechanical studies, clinical studies and application principles, effects on toggling in the cavity, and related complications of distal interlocking screws. The mode of the distal interlocking screw holes can be divided into static and dynamic. Distal interlocking screws play the role of anti-rotation, maintaining femur length, resisting compression stress, increasing torque stiffness, resisting varus stress, etc. The number of the screws directly affects the toggling of the main nail in the cavity. At present, regardless of whether long or short nails are used, distal interlocking screws are routinely inserted in clinical practice. However, using distal interlocking screws can significantly increase the duration of anesthesia and operation, increase fluoroscopy exposure time, surgical blood loss, and incision length. There is a trend of trying not to use distal interlocking screws in recent years. No significant difference is found in some studies between the effectiveness of dynamic and static interlocking for AO/Orthopaedic Trauma Association (AO/OTA) 31-A1/2 fractures. At present, the selection of the number and mode of distal interlocking screws is still controversial. When inserting distal interlocking screws, orthopedists should endeavor to minimize the occurrence of complications concerning miss shot, vascular injuries, local stress stimulation, and peri-implant fractures. Distal interlocking screws are mainly used to prevent rotation. For stable fractures with intact lateral walls, long cephalomedullary nails can be used without distal interlocking screws. For any type of intertrochanteric fractures, distal interlocking screws are required when using short cephalomedullary nails for fixation. Different interlocking modes, the number of interlocking screws, and the application prospects of absorbable interlocking screws may be future research directions.

Single catheter approach for treatment of premature ventricular contractions.

Catheter ablation has become one of the main treatment strategies in patients with premature ventricular complexes (PVC).The successful mapping and ablation can be performed with an ablation catheter without additional diagnostic catheters. We hypothesize that using a single catheter for PVC ablation may decrease complications, procedure time, and fluoroscopy exposure while maintaining comparable success rates. Sixty-nineconsecutive patients with PVC were treated with a single catheter approach compared to a historical cohort, in which a conventional setup was used. Propensity score matching was conducted with a 1:1 ratio. Outcome parameters included acute procedural success with elimination of all premature ventricular contractions after catheter ablation, procedural data as well as complication rates. Patients treated with a single catheter approach had shorter total procedure (60 minutes [IQR:47,5-69,0 minutes] vs. 90 minutes [IQR60-120 minutes]; p = 0.001) and fluoroscopy times (218 seconds[IQR:110,5-446 seconds] vs. 310 seconds[IQR190-640 seconds]; p = 0.012), which consecutively leads to a reduction of radiation exposure signified by a lower dose area product (155 cGycm² [IQR74.4-334.5 cGycm²] vs. 368.4 cGycm² [IQR:126-905.4 cGycm²]; p value 0.009). Acute procedural success rates were comparable in both groups (54 [84.3%] in the single catheter approach group and 58 [90.6%] in the conventional group; p: 0.287). A single catheter approach for the treatment of PVC is associated with a reduction of procedure- and fluoroscopy time, as well as a lesser radiation exposure, while maintaining equivalent acute success and complication rates compared with a conventionally used catheter setup.

Robotic Precision vs. Human Dexterity—Benchtop Comparative Study of Free-Hand vs. Robotic-Assisted Puncture in Fluoroscopy-Guided Percutaneous Nephrolithotomy

Introduction: Percutaneous nephrolithotomy (PCNL) is the standard procedure for treating large kidney stones, especially those measuring over 20 mm or staghorn stones. Accurate placement of the tract into the renal collecting system of interest is crucial. Objective: To compare the free-hand puncture technique with robotic-assisted puncture during fluoroscopy-guided PCNL on a phantom kidney model in terms of efficiency and safety. A self-assessment of confidence levels after each puncture was recorded. Study Design: This prospective single-center benchtop study was conducted at the University Malaya Medical Centre (UMMC). Four urological residents participated and performed phantom punctures using both the free-hand bull’s eye technique and the automated needle targeting system with X-ray (ANT-X). Each resident performed a total of 60 punctures on the renal phantom models, with 30 punctures using the free-hand technique and 30 punctures using the ANT-X robotic-assisted system. Results: A total of 240 needle insertions were conducted, with 120 in the ANT-X group and 120 in the free-hand group. The success rate of needle insertions was 100% in both groups. However, the study revealed that the ANT-X group required, on average, an additional 51 s for needle puncture compared to the free-hand group (p &lt; 0.001). In terms of fluoroscopic exposure, the ANT-X group exhibited significantly lower radiation exposure compared to the free-hand group (p &lt; 0.001). Sub-analysis showed that puncture time remained consistent regardless of the technique used, but fluoroscopic screening time decreased with increasing participant experience. The ANT-X group also resulted in significantly lower radiation exposure during initial sessions compared to the free-hand technique. Surgeons’ self-assessment of confidence levels indicated a high level of confidence in needle puncture. Conclusions: Our benchtop study comparing the efficacy and safety between free-hand and ANT-X phantom punctures revealed comparable results. The needle puncture technique facilitated by the ANT-X system showed promising results in terms of reducing fluoroscopic exposure, albeit at the cost of longer operative times. This technology holds promise for novice surgeons who are in the early stages of their learning curve and might be useful for experienced surgeons looking to reduce radiation exposure.

Choice of Entry Point Does Not Affect Clinical and Radiological Outcomes in Antegrade Intra-medullary Nailing in Patients with Shaft of Femur Fracture: A Prospective Randomized Controlled Trial.

The choice of entry point, Greater trochanter (GT), or Piriformis entry (PE) for antegrade intramedullary nailing (IMN) of the femur is crucial. This study was performed to compare these two entry points in the patients with shaft of femur fractures regarding intra-operative parameters, radiological and functional outcomes. Twenty-four patients underwent GT entry nailing, while 25 patients underwent PE nailing. Surgical time, Intra-operative blood units transfused, Intra-operative fluoroscopy exposure by number of C-arm shots taken, mean drop in hemoglobin, and incidence of iatrogenic fracture were recorded. Patients were followed up at 4weeks, 6weeks, and 6months to look for radiological healing and improvements in functional outcome using Modified Harris Hip Score (MHHS). MRI of bilateral hips with pelvis was done in 25 patients at 6months of follow-up to detect any preliminary signs of AVN. The mean drop in hemoglobin in the GT group was significantly lesser than the PE group (p = 0.02). Mean MHHS at 4weeks post-op was also significantly higher in the GT group (p = 0.01). There was no significant difference between both the groups regarding surgical duration, fluoroscopy exposure, radiological and functional outcomes in the long term. None of the patients who underwent MRI displayed any preliminary sign of AVN. GT entry nails lead to lesser surgical time, fluoroscopy exposure, and intra-operative blood loss. Both the nailing systems achieve excellent fracture unions and comparable functional outcomes in the long term, and there is a minuscule risk of AVN in adult patients undergoing IMN.

Intracardiac echocardiography in paediatric and congenital cardiac ablation shortens procedure duration and improves success without complications.

Common to adult electrophysiology studies (EPSs), intracardiac echocardiography (ICE) use in paediatric and congenital heart disease (CHD) EPS is limited. The purpose of this study was to assess the efficacy of ICE use and incidence of associated complications in paediatric and CHD EPS. This single-centre retrospective matched cohort study reviewed EPS between 2013 and 2022. Demographics, CHD type, and EPS data were collected. Intracardiac echocardiography cases were matched 1:1 to no ICE controls to assess differences in complications, ablation success, fluoroscopy exposure, procedure duration, and arrhythmia recurrence. Cases and controls with preceding EPS within 5 years were excluded. Intracardiac echocardiography cases without an appropriate match were excluded from comparative analyses but included in the descriptive cohort. We performed univariable and multivariable logistic regression to assess associations between variables and outcomes. A total of 335 EPS were reviewed, with ICE used in 196. The median age of ICE cases was 15 [interquartile range (IQR) 12-17; range 3-47] years, and median weight 57 [IQR 45-71; range 15-134] kg. There were no ICE-related acute or post-procedural complications. There were 139 ICE cases matched to no ICE controls. Baseline demographics and anthropometrics were similar between cases and controls. Fluoroscopy exposure (P = 0.02), procedure duration (P = 0.01), and arrhythmia recurrence (P = 0.01) were significantly lower in ICE cases. Intracardiac echocardiography in paediatric and CHD ablations is safe and reduces procedure duration, fluoroscopy exposure, and arrhythmia recurrence. However, not every arrhythmia substrate requires ICE use. Thoughtful selection will ensure the judicious and strategic application of ICE to enhance outcomes.

One-year outcomes of wide antral cryoballoon ablation guided by high-density mapping vs. conventional cryoballoon ablation for atrial fibrillation: a propensity score-matched study.

Pulmonary vein isolation with wide antral ablation leads to better clinical outcomes for the treatment of atrial fibrillation, but the isolation lesion is invisible in conventional cryoballoon ablation. In this study, we aim to investigate the efficacy of the wide pulmonary vein isolation technique that includes the intervenous carina region, guided by high-density mapping, compared with pulmonary vein isolation alone without the mapping system. We conducted a propensity score-matched comparison of 74 patients who underwent a wide cryoballoon ablation guided by high-density mapping (mapping group) and 74 controls who underwent conventional cryoballoon ablation in the same period (no-mapping group). The primary outcome was a clinical recurrence of documented atrial arrhythmias for >30 s during the 1-year follow-up. Of 74 patients in the mapping group, residual local potential in the pulmonary vein antrum was found in 30 (40.5%) patients, and additional cryothermal applications were performed to achieve a wide pulmonary vein isolation. Compared with the no-mapping group, the use of the mapping system in the mapping group was associated with a longer fluoroscopic time (26.97 ± 8.07 min vs. 23.76 ± 8.36 min, P = 0.023) and greater fluoroscopic exposure [339 (IQR181-586) mGy vs. 224 (IQR133-409) mGy, P = 0.012]. However, no significant differences between the two groups were found in terms of procedural duration and left atrial dwell time (104.10 ± 18.76 min vs. 102.45 ± 21.01 min, P = 0.619; 83.52 ± 17.01 min vs. 79.59 ± 17.96 min, P = 0.177). The rate of 12-month freedom from clinical atrial arrhythmia recurrence was 85.1% in the mapping group and 70.3% in the no-mapping group (log-rank P = 0.029). Voltage and pulmonary vein potential mapping after cryoballoon pulmonary vein isolation can identify residual potential in the pulmonary vein antrum, and additional cryoablation guided by mapping leads to improved freedom from atrial arrhythmias compared with conventional pulmonary vein isolation without the mapping system. ChiCTR2200064383.

Endoscopic Revision Strategies and Outcomes for Recurrent L4/5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy.

We explore the endoscopic revision and surgical techniques for L4/5 recurrent disc herniation (rLDH) after percutaneous endoscopic transforaminal discectomy (PETD). A retrospective study was conducted. From January 2016 to September 2022, 96 patients who underwent percutaneous endoscopic lumbar discectomy for L4/5 rLDH after PETD were enrolled in the study. Based on the revision approach, the patients were divided into PETD group (57 cases) and percutaneous endoscopic interlaminar discectomy (PEID) group (39 cases). Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and modified MacNab standard were recorded to evaluate the clinical outcomes. No significant differences were found in the demographic data and intraoperative blood loss between the two groups (P>0.05), but the time of operation and intraoperative X-ray fluoroscopy exposures in the PEID group were significantly less than that in the PETD group (P<0.05). The patients' postoperative clinical indexes gradually improved, and the VAS score, ODI index, and JOA score of the patients in both groups showed significant improvement compared with the preoperative period at the 1-week, 1-month, and 6-month postoperative follow-ups (P < 0.05). There was no serious complication observed during the follow-up. For recurrent LDH after PETD of L4/5 segments, percutaneous endoscopic revision can achieve satisfactory results. Among them, PEID has a shorter operative and fluoroscopy time and allows avoidance of the scar that forms after the initial surgery, so it can be considered preferred when both procedures can remove the disk well. However, for some specific types of herniation, a detailed surgical strategy is required.

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fracture treatment and risk factor screening for postoperative refracture.

Osteoporotic vertebral compression fracture (OVCF) is a serious complication of osteoporosis, and percutaneous vertebroplasty (PVP) is a major therapeutic method for OVCF. This study aimed to evaluate the clinical efficacy and postoperative complications of robot-assisted targeted PVP for the treatment of OVCF. The data from 202 OVCF patients were analyzed in this study, including 72 cases received traditional PVP (PVP group), 68 cases received robot-assisted PVP (R-PVP group), and 62 cases underwent robot-assisted PVP combined with targeted plugging (R-PVP + TP group). The fluoroscopic exposure conditions, operative duration, lengths of stay, postoperative bone cement leakage, refracture, Visual Analog Scale (VAS) score, and Oswestry Disability Index (ODI) score were obtained and compared between the three groups. The Kaplan-Meier method and logistic regression model were adopted to screen the risk factors related with postoperative refracture. R-PVP and R-PVP + TP group had significantly reduced fluoroscopic frequency and radiation dose, and reduced cement leakage compared with PVP group. R-PVP + TP not only showed more obvious advantages in these aspects, but also had a lower probability of postoperative refracture. In addition, BMD, fracture vertebral distribution, cement leakage, and surgery methods were independent related with refracture. All the results demonstrated robot assistance could improve the application of PVP in the treatment of OVCF, and robot-assisted PVP combined with targeted plugging showed significantly reduced fluoroscopic exposure, bone cement leakage, and rate of postoperative refracture. BMD, fracture vertebral distribution, cement leakage, and operation methods were identified as four risk factors for the onset of refracture after PVP.

Evaluation of Cytogenetic Damage Induced during Hysterosalpingography Procedure: A Cross-sectional Study

Introduction: Hysterosalpingography (HSG) is a radiographic procedure used to visualise the fallopian tubes and uterine cavity by injecting a contrast medium, commonly employed for diagnosing infertility cases. However, due to the associated radiographic and fluoroscopic exposure, there is an increased risk of chromosomal damage to the gonads. Aim: To investigate the impact of radiographic and fluoroscopic exposure on chromosomal integrity in peripheral blood lymphocytes using the Cytokinesis Blocked Micronucleus (CBMN) assay. Materials and Methods: This cross-sectional time-bound study included 10 patients (n=10) scheduled for HSG procedures at the Department of Radiology, Justice KS Hegde Hospital, Mangaluru, Karnataka, India from April 2021 to March 2022. Following radiation exposure, the CBMN assay was conducted to evaluate chromosomal damage in both test and control group blood samples. Blood samples from healthy donors were divided into three cryo vials, with one serving as the control and the remaining two exposed to radiation at the entrance and exit areas during the HSG procedure. The data were expressed as mean±Standard Deviation (SD). A p-value &lt;0.05 was considered statistically significant. The analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0. Results: A statistically significant (p&lt;0.05) increase in biological damage was observed when comparing the Micronucleus (MN) frequency of the test groups (entrance=0.022±0.005 and exit group=0.0172±0.005) with the control group (0.006±0.003). Additionally, a decrease in MN frequency was noticed within the test groups, particularly in the exit group, although the results were not statistically significant (p=0.066). Conclusion: The HSG is an effective clinical diagnostic technique. However, the present study indicates a potential risk of chromosomal damage associated with the procedure, emphasising the need for judicious use of radiation exposure during HSG.

Effect of a Percutaneous Screw Guide on Screw Placement for Posterior Talar Fractures.

This study aimed to evaluate the hypothesis that the utilization of percutaneous screw guides enhances the precision of screw placement in the surgical fixation of talar fractures. Computed tomography (CT) scans of ankle joints were obtained from 40 healthy adults and 10 cadaveric specimens between April 2019 and August 2020 at Ningbo No. 6 Hospital. The acquired CT data were imported into Materialise Interactive Medical Image Control System (MIMICS) software for processing. Three-dimensional (3D) digital models of the ankle joints were reconstructed, and relevant anatomical parameters were measured. A percutaneous screw guide (PSG) was designed and fabricated to facilitate accurate screw placement in the posterior talar process. Ten eligible cadaveric ankle joints were selected for further analysis and their 3D models were reconstructed using the MIMICS software. Screw trajectory parameters were then measured and analyzed based on these cadaveric models, forming the model group for comparative analyses. Ten cadaveric specimens were utilized in this study, equally divided into two groups: a guider group (n = 5) and a free-hand group (n = 5). In the guider group, talar posterior process screws were inserted using percutaneous screw guidance. In the free-hand group, screws were inserted into the talar posterior process without guidance. Post-operative CT scans were performed on all specimens. The following parameters were quantitatively compared between the two groups: screw trajectories, entry point distances in specimens with preselected screws, entry point distance trajectories in the 3D model, operation time, frequency of fluoroscopic imaging, and number of drilling attempts. Following the generation of the 3D models from 10 cadavers, a virtual screw was digitally inserted into each model. In the model group, the preselected screw trajectory was oriented towards the medial aspect of the talar neck base, with a cephalad inclination angle (CIA) of 3.1° ± 1.5° in the transverse~plane and a medial diverge angle (MDA) of 12.0° ± 1.4° in the coronal plane. The CIA and MDA of the screw trajectory in the guider group were 2.1° ± 1.7° and 11.2° ± 1.6°, respectively, whereas the CIA and MDA in the free-hand group were 6.0° ± 2.2° and 18.8° ± 1.6°, respectively. Statistical analysis revealed significant differences in both CIA and MDA between the two groups (p < 0.05). Furthermore, the guider group yielded superior outcomes in terms of entry point distance, operation time, fluoroscopic exposure time, and number of drilling attempts compared to the free-hand group (p < 0.05). Percutaneous screw guidance can improve the accuracy and safety of the posterior process of the talar screws, which can be feasible for percutaneous fixation. Further studies are required to confirm the efficacy and clinical outcomes of percutaneous screw guidance.

Feasibility study of cryoballoon ablation for atrial fibrillation with KODEX-EPD: a single center experience

To evaluate the feasibility of cryoballoon (CB) ablation of atrial fibrillation (AF) under the guidance of a new three-dimensional (3D) mapping system KODEX-EPD. 40 patients scheduled for CB ablation of AF in the first affiliated Hospital of Xinjiang Medical University from August 2021 to July 2022 were randomly divided into two groups: KODEX-EPD 3D mapping system guidance group (KODEX group, n = 20) and conventional two-dimensional perspective group (standard group, n = 20). The ablation time, operation time, fluoroscopy time, fluoroscopy dose, contrast agent dosage and follow-up data were compared between the two groups. Besides, the feasibility and accuracy of the dielectric sensing system in evaluating pulmonary vein (PV) occlusion in patients with AF during CB ablation were verified. All pulmonary veins were being isolated. The ablation time (36.40 ± 6.72 min vs 35.15 ± 6.29 min, P > 0.05) and the operation time (64.20 ± 11.82 min vs 66.00 ± 13.18 min, P > 0.05) were not statistically different in the two groups. The standard group has longer fluoroscopy time, dose and contrast medium dosage. There were significant differences in fluoroscopy time (532.30 ± 72.83 s vs 676.25 ± 269.33 s, P < 0.05), fluoroscopy dose (110.00 ± 28.64 mGy vs 144.68 ± 66.66 mGy, P < 0.05), and contrast medium dosage (71.90 ± 5.97 ml vs 76.05 ± 5.93 ml, P < 0.05) between the two groups. The learning curves of the first 5 patients and the last 15 patients in the KODEX group were compared. There was no statistical difference in the ablation time (36.80 ± 8.56 min vs 36.27 ± 6.34 min, P > 0.05) or the operation time (69.00 ± 5.00 min vs 62.60 ± 13.10 min, P > 0.05); however, compared to the first 5 patients, fluoroscopy time (587.40 ± 38.34 s vs 513.93 ± 73.02 s, P < 0.05), fluoroscopy dose (147.85 ± 35.19 mGy vs 97.39 ± 8.80 mGy, P < 0.05) and contrast medium dosage (79.60 ± 1.14 ml vs 69.33 ± 4.45 ml, P < 0.05) were significantly decreased. Using pulmonary venography as the gold standard, the sensitivity, specificity of the completely occlusion in KODEX group was 93.6% (95% CI 85–97.6%) and 69.6% (95% CI 54–81.8%); and the sensitivity, specificity of the small leak in KODEX group was 93.1% (95% CI 82.4–97.8%) and 82.0% (95% CI 65.9–91.9%). During an average follow-up of (9.90 ± 1.06) months, there was no statistical difference in arrhythmia recurrence and antiarrhythmic drugs taking after CB ablation between the two groups (P > 0.05). Using the KODEX-EPD system, the CB ablation procedure can correctly evaluate the PV occlusion, and significantly reduce fluoroscopy exposure and contrast medium without significantly increasing the operation time.

Patient and physician radiation exposure during minimally invasive lumbar decompression: A prospective assessment of X-ray exposure risks.

Minimally invasive lumbar decompression (mild®) is becoming a popular procedure for treating lumbar spinal stenosis (LSS) secondary to hypertrophic ligamentum flavum (LF). The mild® procedure is commonly performed under live fluoroscopic guidance and carries a risk of radiation exposure to the patient and healthcare. One physician performed mild® on 41 patients at the Cleveland Clinic Department of Pain Management from October 2019 to December 2021, while wearing a radiation exposure monitor (Mirion Technologies). Mean fluoroscopy time, mean exposure per case, and mean exposure per unilateral level decompressed were the primary outcomes measured. The secondary outcome was to provide a comparison of radiation exposure during similar fluoroscopically guided procedures. Mean patient fluoroscopy exposure time was 2.1 min ±0.9 (range: 1.1-5.6) fluoroscopy time per unilateral level decompressed. The mean patient radiation skin exposure from mild® was 1.1 ± 0.9 mGym2, and the mean total dose was 142.3 ± 108.6 mGy per procedure. On average, the physician was exposed to an average deep tissue exposure of 4.1 ± 3.2 mRem, 2.9 ± 2.2 mRem estimated eye exposure, and 14.7 ± 11.0 mRem shallow tissue exposure per unilateral level decompressed. An individual physician would exceed the annual exposure limit of 5 Rem after approximately 610 mild® procedures per year. This study is an attempt to quantify the radiation exposure to the physician and patient during the mild® procedure. Compared with other fluoroscopically guided pain management procedures, patient and physician radiation exposure during mild® was low.

Comparison of Radial Versus Femoral Access for Neuroendovascular Procedures in Very High Body Mass Index Individuals

Background and ObjectivesFemoral access (TFA) for neuroendovascular procedures may present a challenge in very high body mass index (BMI) individuals. Whether Radial access (TRA) confers a comparative benefit in this specific population has not been studied. MethodsWe retrospectively identified all patients undergoing neuroendovascular procedures at our center between 2017-2021 with BMI ≥ 35 kg/m2. 335 patients met our inclusion criteria, with 224 undergoing femoral access and 111 undergoing radial access. Electronic medical records were reviewed for baseline clinical and angiographic characteristics and procedural outcomes. ResultsThe primary outcome of any bleeding complication occurred in 7% of the femoral group and 2% of the radial group (odds ratio [OR] 4.2, 95% CI 1.0 - 18.6, p = 0.0421). Radial access was also associated with significantly shorter mean procedure times (median 43 minutes for radial, median 58 minutes for femoral, p = 0.0009) and mean fluoroscopy exposure times (median 15 minutes for radial, median 20 minutes for femoral, p = 0.0003). There were no significant differences in non-access site complications, procedural failure, length of stay, or deaths during hospitalization. ConclusionWhen compared to TRA, TFA was associated with a significantly greater rate of bleeding complications in very high BMI patients undergoing neuroendovascular procedures. Procedure time and fluoroscopy time were both significantly longer when using TFA compared to TRA in this patient population.

Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal–diaphyseal junction fractures of the distal radius: a case-control study

BackgroundSeveral methods have been used for the treatment of pediatric distal radius fractures, such as the elastic stable intramedullary nail (ESIN), Kirschner wire (K-wire), and plate, but there has been no consensus about the optimum method. The purpose of this study was to compare ESIN and K-wire techniques used in metaphyseal–diaphyseal junction (MDJ) fractures of the pediatric distal radius.MethodsThe data of patients who were treated at a children’s hospital affiliated with Shandong University between August 2018 and January 2022 were analyzed retrospectively. The children were divided into the ESIN and K-wire groups. Clinical outcomes were measured by the Gartland and Werley scoring system. Variables were analyzed using a statistical approach between the two groups.ResultsThe study included 26 patients, of whom 11 were treated with K-wire and 15 with ESIN. At the final follow-up, all of the fractures were healed. There were no differences in terms of age, sex, fracture location, or wrist function score. However, the ESIN was superior to K-wire in operative time, fluoroscopic exposure, and estimated blood loss (EBL).ConclusionsK-wire and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal radius. The use of the ESIN technique represents less EBL, fluoroscopy exposure, and operation time compared with K-wire. We recommend osteosynthesis by ESIN rather than K-wires in patients with MDJ fractures of the distal radius.Level of evidenceIII, a case-control study.

Retrograde tibial intramedullary nail versus minimally invasive locking plate for extra-articular distal tibial fractures: A comparative and retrospective study

BackgroundThe fractures of distal tibia represent common lower limb injuries, frequently accompanied by significant soft tissue damage. The optimal surgical approach for these fractures remains a considerable debate. This study was to perform a comparative analysis of retrograde intramedullary tibial nails (RTN) and minimally invasive plate osteosynthesis (MIPO) for extra-articular distal tibial fractures. Patients and methodsBetween December 2019 and December 2021, a retrospective review was conducted on 48 patients who sustained extra-articular distal tibial fractures. Patients underwent either RTN or MIPO procedures. Operative duration, intraoperative fluoroscopy exposure, time to union, duration until full weight-bearing, American Orthopedic Foot and Ankle Society (AOFAS) scores, and related complications were recorded and compared between the two groups. ResultsNo statistically differences were observed in operative duration, time to union, angulation of the distal tibial coronal plane, or AOFAS scores between RTN and MIPO groups. However, the RTN group had a higher average number of intraoperative fluoroscopy images (8.2 ± 2.3) compared to the MIPO group (4.1 ± 2.0). The RTN group demonstrated shorter average hospital stays (7.1 ± 1.4 days) and a quicker return to full weight-bearing (9.9 ± 1.3 weeks), which were significantly superior to the MIPO group (9.0 ± 2.0 days and 11.5 ± 1.5 weeks, respectively). In terms of complications, the RTN group had one case of superficial infection, whereas the MIPO group exhibited two cases of delayed union and nonunion, one instance of implant failure, two occurrences of deep infection, and an additional three cases of superficial infection. The complications rate was remarkably higher in the MIPO group. ConclusionBoth RTN and MIPO are effective treatment options for extra-articular distal tibial fractures. However, RTN may offer superior outcomes in terms of reduced hospital stay duration, faster return to full weight-bearing capacity, and a lower rate of complications.

Comparison of Radiation Exposure for Pregnant Patients Requiring Intervention for Suspected Obstructing Nephrolithiasis

To identify the differences in radiation exposure per suspected stone episode between percutaneous nephrostomy tube (PCN), stent, and primary ureteroscopy (URS).The incidence of nephrolithiasis in pregnancy is low; however, repercussions for both mother and fetus can be significant. In cases of suspected obstructing nephrolithiasis, intervention may be required, including ureteral stent, PCN, or URS, with the potential for multiple subsequent procedures that often utilize fluoroscopy. Pregnant patients who required an intervention (stent, PCN, or URS) for suspected obstructing nephrolithiasis were retrospectively reviewed. The primary outcome was total fluoroscopy exposure per suspected stone episode. Secondary outcomes included fluoroscopic exposure per procedure and number of procedures required. After excluding patients with renal anomalies and incomplete radiation data, 78 out of 100 patients were included in the analysis. Forty patients (51.3%) underwent initial stent placement, 22 (28.2%) underwent initial PCN placement, and 16 (20.5%) underwent primary URS. Total mean radiation exposure per stone episode was significantly higher in patients who underwent PCN, (286.9mGy vs 3.7mGy (stent) and 0.2mGy (URS), P<.001). In addition, patients who underwent initial PCN placement had significantly more procedures (P<.001) and mean radiation exposure per procedure was higher (P<.001). More than 40% of PCNs experienced dysfunction, and mean duration between PCN exchanges was 16.5days. In pregnant patients with suspected obstructing nephrolithiasis requiring intervention, initial PCN placement was associated with a significantly higher number of procedures, radiation exposure per procedure, and total radiation exposure per suspected stone episode compared to stent and URS.