Fluoroscopy Group Research Articles

Fluoroscopy-guided placement of pull-type gastrostomy tubes; a single-center experience

Aim: Gastrostomy tubes provide nutritional access in patients with impaired oral intake. Gastrostomy tubes can be inserted with endoscopy or fluoroscopy assistance. The aim of this study was to describe the clinical features and complications of fluoroscopy-guided gastrostomy tube insertion and to compare these complications with those of the endoscopy-assisted gastrostomy technique.Material and Methods: A retrospective data analysis was performed for gastrostomy tube placement procedures. Patients’ age, gender, medical, neurological, and surgical diseases, major and minor complications, mortality rates, and length of hospital stay were compared between fluoroscopy-guided and endoscopy-guided pull-type gastrostomy tube placement. Results: The medical records of 92 patients (60 male, 32 female; mean age ± SD: 63.1 ± 15.8 years; range: 24-92 years) who underwent endoscopy-guided (n=50) or fluoroscopy-guided (n=42) gastrostomy tube placement were reviewed. The indications for gastrostomy tube insertion mainly included neurological disease (n=39, 78%), such as cerebrovascular accident (n=22, 44%), in the endoscopy group and surgical disease (n=33, 73.3%), such as head and neck cancer (n=27, 60%), in the fluoroscopy group. There were no mortalities related to gastrostomy tube insertion in either group. There was no significant difference between the major complication rates of the two groups (P=0.62). The minor complication rate was higher in the endoscopy group (P=0.03). One patient in the fluoroscopy group required surgical intervention to treat a complication related to gastrostomy insertion.Conclusion: Gastrostomy tube insertion via both endoscopy and fluoroscopy guidance provides a safe route for nutrition delivery. Fluoroscopy-guided placement of pull-type gastrostomy tubes is a reliable technique and should be the first choice for gastrostomy tube placement, particularly for patients with head and neck tumors in whom endoscopic placement is technically difficult.

Effectiveness of Ultrasonography and Fluoroscopy as a Therapeutic Imaging Modality in the Management of Lumbar Facet Arthropathy: A Prospective Interventional Study

Introduction: Lumbar zygopophyseal joint arthropathy is one of the most common causes of low back pain in adults. Historically, C-arm/Fluoroscopy has served as an image guidance tool in intra-articular facet joint injections, however, now ultrasound guidance is also a viable option. Aim: To compare ultrasonography (USG) and fluoroscopy as therapeutic imaging modalities on the basis of time taken for intervention, Visual Analogue Score (VAS) for pain and Oswestry Disability Index (ODI) at 2, 4 and 12 weeks. Materials and Methods: It was a prospective interventional study done with 62 patients who satisfied the inclusion and exclusion criteria and randomly allocated into two groups. Groups were compared on the basis of time taken for intervention, VAS for pain and ODI at 2, 4 and 12 weeks. Independent sample student t-test/Mann-Whitney U test was applied. Confidence Interval (CI) was taken as 95% and p-value <0.05 was considered as statistically significant. Results: Ultrasound group had mean age of 37.75 years (range, 23-55 years) while that of Fluoroscopy group was 40.05 years (range, 20-54 years). Ultrasonography group was quicker by about 135 seconds (2 minutes and 15 seconds) which was statistically significant but there was statistically no difference between the two groups in terms of VAS and ODI at 2 weeks (p=0.107 and 0.893, respectively), 4 weeks (p=0.383 and 0.408, respectively) and 12 weeks (p=0.343 and 0.777, respectively) at 95% CI. Conclusion: Both groups showed significant improvement in pain and disability after 2, 4 and 12 weeks however there were no significant differences in pain and functional improvement between USG guided transverse view and fluoroscopy guided intra-articular lumbar facet joint injection. Therefore, USG guided transverse approach is quicker, feasible and minimises exposure of radiation to patient as well as interventionist

A Practical Method for Ablation Catheter Reintroduction into the Left Atrium via Prior Transseptal Puncture, without Radiation.

We evaluated the feasibility and safety of reintroducing an ablation catheter (ABL) into the left atrium (LA) through a previously punctured interatrial septum under guidance of the show-catheter image-track function of the CARTO 3 3-dimensional (3D) electroanatomic mapping system. One hundred consecutive paroxysmal or persistent drug-refractory atrial fibrillation (AF) patients (men: 55; mean age, 64.7 ± 12.1 years) who had undergone 2 fluoroscopy-guided transseptal punctures and anatomical LA reconstruction under CARTO 3-guidance, and required ABL reinsertion into the LA during mapping or ablation, were included. They were randomized 1:1 to the show-catheter (reintroduction under the CARTO 3 show-catheter image-track function) or fluoroscopy group (reintroduction under conventional fluoroscopy). Although the reconstructed 3D anatomy map was displaced in 21/100 patients (21.0%), the ABL was successfully reintroduced in all patients. In the show-catheter and fluoroscopy groups, model displacement incidence (18% versus 24%), tachyarrhythmias (46.0% versus 52.0%), complications (2% versus 4%), and number of ABLs reintroduced into the LA (3.3 ± 0.8 versus 3.1 ± 0.9) were similar (all P > .05). The show-catheter group displayed shorter ABL reintroduction time (9.5 ± 5.5 s versus 156.4 ± 35.5 s, P < .01), ABL reintroduction X-ray exposure time (0 s versus 39.3 ± 13.8 s, P < .01), and total X-ray exposure time (4.1 ± 1.4 min versus 4.7 ± 0.8, P < .05). During AF ablation, the catheter can be safely reintroduced into the LA, without additional fluoroscopy, under guidance of the CARTO 3 show-catheter image track function.

Intraoperative fluoroscopy reduces the variability in femoral tunnel placement during single-bundle anterior cruciate ligament reconstruction.

To evaluate the effect of using intraoperative fluoroscopy on femoral and tibial tunnel positioning variability in single-bundle anterior cruciate ligament (ACL) reconstruction. A total of 80 consecutive patients with single-bundle ACL reconstruction between 2014 and 2016 were retrospectively reviewed. Among them, 40 underwent ACL reconstruction without fluoroscopy (non-fluoroscopy group) and 40 underwent fluoroscopy-assisted ACL reconstruction (fluoroscopy group). Femoral and tibial tunnel locations were evaluated using a standardized grid system with three-dimensional computed tomography images. Femoral and tibial tunnel location variability was compared between the groups. The operation time was longer in the fluoroscopy group than in the non-fluoroscopy group (61.3 ± 5.2min vs. 55.5 ± 4.5min, p < 0.001). In the fluoroscopy group, a guide pin was repositioned in 16 (40%) cases on the femoral side and 2 (5%) cases on the tibial side. No significant difference in the femoral tunnel location was observed between the fluoroscopy and non-fluoroscopy groups (anterior-posterior plane, 29.0% ± 3.2% vs. 30.0% ± 6.1%; proximal-distal plane, 30.8% ± 4.8% vs. 29.4% ± 8.3%; all parameters, n.s.); variability was significantly lower in the fluoroscopy group (p < 0.001 for both anterior-posterior and proximal-distal planes). No significant difference in the tibial tunnel location and variability was observed between the fluoroscopy and non-fluoroscopy groups (medial-lateral plane, 45.8% ± 2.0% vs. 46.6% ± 2.4%; anterior-posterior plane, 31.2% ± 4.0% vs. 31.0% ± 5.4%) (all parameters, n.s.). Tunnel positioning with fluoroscopic assistance is feasible and effective in achieving consistency in femoral tunnel placement despite a slightly longer operation time. Intraoperative fluoroscopy can be helpful in cases wherein identifying anatomical landmarks on arthroscopy was difficult or for surgeons with less experience who performed ACL reconstruction. IV.

Reduced Puncture Time and Radiation Exposure of Percutaneous Transpedicular Puncture with Electronic Conductivity Device: A Randomized Clinical Trial

The present study introduced an electronic conductivity device (ECD) to reduce time of percutaneous transpedicular puncture and frequency of patient valid radiation exposure in percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP). A randomized self-control clinical study was undertaken. Medical records of patients with vertebral compression fractures (VCFs) for bilateral PKP or PVP were collected, and each side was performed randomly with ECD or conventional trocar. We enrolled 61 patients (44 women, 17 men) with 75 vertebras with VCF. Compared with the conventional fluoroscopy group, significant reductions in puncture time (504.33 ± 152.03 vs. 652.68 ± 167.60 seconds; P < 0.001) and fluoroscopy frequency (5.11 ± 1.23 vs. 8.15 ± 1.83; P < 0.001) for each percutaneous puncture were observed in the ECD group. When compared with the VCFs ≤50% group, the 2 indexes in the VCFs >50% group were significantly increased. And in the ECD group, the learning curve in the VCFs >50% group showed a steeper decreasing trend than that in the VCFs ≤50% group. No complications were observed in any patient. ECD could reduce puncture time of percutaneous transpedicular puncture and exposure of radiation in PVP and PKP. ECD has more benefits in complicated transpedicular puncture in patients with vertebral compression >50%.

174. Analysis of radiological accuracy among different intraoperative imaging systems for screw fixation in cervicothoracic region

BACKGROUND CONTEXT Surgical techniques for posterior fixation of cervicothoracic pathologies are challenged by the great variation in pedicle dimension and angulations as well as the risky neurovascular anatomy with the proximity of the spinal cord, nerve roots, and vertebral artery. Intraoperative computed tomography navigation promises improved accuracy of spinal navigation with the benefit of increased visualization of a pedicle's trajectory. Even though multiple studies have demonstrated improved accuracy using navigated instrumentation, it remains a debate how useful iCT imaging is for posterior pedicle and lateral mass screw implantation in the subaxial cervicothoracic spine. PURPOSE The aim of this study was to compare the accuracy of posterior subaxial cervicothoracic fixation using three different techniques: intraoperative computed tomography (iCT-AIRO) scanner-guided navigation, 3D- (O-arm) based spinal navigation and fluoroscopy based posterior stabilization. STUDY DESIGN/SETTING Retrospective analysis of the accuracy of cervicothoracic screw placement in posterior fixation in 3 groups of patients. PATIENT SAMPLE In the period between August 2007 and October 2018, a total of 495 screws were implanted in 67 patients with cervicothoracic instability who underwent posterior fixation. A total of 163 screws were inserted with the use of the iCT based spinal navigation (group A); 310 screws were implanted using the O-arm navigation system (group B), while 22 screws were inserted under the guidance of fluoroscopy (group C). OUTCOME MEASURES Screw positions were evaluated using postoperative CT scans according to the Neo et al (cervical pedicles) and Gertzbein and Robbins (thoracic) classifications. The screws in the cervical lateral mass were evaluated according to a new classification created by the authors. METHODS The assessment of the screw placement was retrospectively done and graded by an independent observer. Accurate positioning was defined then as screws correctly placed completely within the pedicle as well as screws with a breach of less than 2 mm or screws correctly placed within the lateral mass as well as screws with incomplete perforation of the cortex. RESULTS Intraoperative computed tomography-based navigation has permitted a more accurate intraoperative evaluation of the implanted screws and has allowed the immediate correction of misplaced screws. With the use of the iCT, the accuracy rate has reached 97.55% with a much better resolution of the images acquired, while with the O-arm navigation, the accuracy rate has reached 90%. In cervicothoracic posterior stabilizations done with the aid of fluoroscopy, the intraoperative accuracy was not determined and only a final accuracy rate was measured which reached 90%. The most significant difference in accuracy was in the positioning of cervical pedicle screws. Our results have demonstrated an accuracy of 96% with iCT compared to an accuracy of 64% with the O-Arm. The accuracy rates in positioning the cervical lateral mass screws and the thoracic pedicle screws with both the iCT or the O-Arm were almost the same. CONCLUSIONS In subaxial cervicothoracic posterior fixation especially of pedicle screws, the use of iCT-based spinal navigation has demonstrated higher accuracy rates as well as higher quality images allowing more accurate evaluation than with the O-arm-based spinal navigation or fluoroscopy-based systems. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Radiographic Accuracy of Percutaneous Pedicle Screw Placement in Fluoroscopic- Versus CT Navigation-Guided Lumbar Spine Instrumentation

Abstract INTRODUCTION Posterior spinal instrumentation for fusion using intraoperative computed tomography (CT) navigation is gaining traction as an alternative to the conventional two-dimensional fluoroscopic-guided approach to percutaneous pedicle screw placement. However, few studies to date have directly compared outcomes of these 2 minimally invasive instrumentation methods. METHODS A consecutive cohort of patients undergoing primary percutaneous posterior lumbar spine instrumentation for spine fusion was retrospectively reviewed. Revision surgeries or cases converted to open were excluded. Accuracy of screw placement was assessed using a postoperative CT scan with blinding to the surgical methods used. The Gertzbein-Robbins classification was used to grade cortical breach: Grade 0 (&lt;0 mm cortical breach), Grade I (&lt;2 mm), Grade II (2-4 mm), Grade III (4-6 mm), and Grade IV (&gt;6 mm). RESULTS CT navigation was found to significantly improve accuracy of screw placement (P &lt; .022). There was significantly more facet violation of the unfused level in the fluoroscopy group vs the CT group (9% vs 0.5%; P &lt; .0001). There was also a higher proportion of poor screw placement in the fluoroscopy group (10.1% vs 3.6%). No statistical difference was found in the rate of tip breach, inferomedial breach, or lateral breach. Regression analysis showed that fluoroscopy had twice the odds of incurring poor screw placement as compared to CT navigation. CONCLUSION This radiographic study comparing screw placement in minimally invasive fluoroscopy- vs CT navigation-guided lumbar spine instrumentation provides evidence that CT navigation significantly improves accuracy of screw placement, especially in optimizing the screw trajectory so as to avoid facet violation. Long-term follow-up studies should be performed to ascertain whether this difference can contribute to an improvement in clinical outcomes.

Percutaneous kyphoplasty assisted with/without mixed reality technology in treatment of OVCF with IVC: a prospective study

BackgroundThe purpose of this study was to assess the clinical outcome of percutaneous kyphoplasty (PKP) assisted with mixed reality (MR) technology in treatment of osteoporotic vertebral compression fracture (OVCF) with intravertebral vacuum cleft (IVC).MethodForty cases of OVCF with IVC undergoing PKP were randomized into a MR technology-assisted group (group A) and a traditional C-arm fluoroscopy group (group B). Both groups were performed PKP and evaluated by VAS scores, ODI scores, radiological evidence of vertebral body height, and kyphotic angle (KA) at pre-operation and post-operation. The volume of injected cement, fluoroscopy times, and operation time were recorded. And cases of non-PMMA-endplates-contact(NPEC) in radiological evidence was also recorded postoperatively. The clinical outcomes and complications were evaluated afterwards. All patients received 10 to 14 months follow-up, with an average of 12 months.ResultThis MR-assisted group (group A) acquired more about the amount of the polymethyl methacrylate (PMMA) injection and postoperative vertebral height and less about postoperative KA, fluoroscopy times, and operation time compared with the control group (group B) (P < 0.05). The VAS scores and ODI scores in both groups have improved, but more significantly in group A (P < 0.05). Also, more cases achieve both-endplates-touching of cement in group A (P < 0.05). And there are less of the loss of vertebral height, KA, and occurrence of re-collapse of the vertebra in group A during the follow-up (P < 0.05).ConclusionPKP assisted with MR technology can accurately orientate the position of IVC area, which can be augmented by the balloon leading to more satisfied vertebral height improvement, cement diffusion, and pain relief.Trial registrationClinicalTrials.gov Identifier: NCT03959059. Registered 25 September 2016.

Catheter ablation of left-sided accessory pathways in small children.

BackgroundAccessory pathways (APs) are a common reason for supraventricular tachycardia in small children. Trans‐septal puncture (TSP) approach is commonly used for the ablation of left‐sided APs, however it may be challenging in small children. The aim of this study was to assess the efficacy and safety of trans‐septal approach radiofrequency (RF) ablation of left‐sided APs in children weighing up to 30 kg.MethodsOf the 658 children who underwent catheter ablation of APs since 06/2002, 86 children had left‐sided AP and weighed less than 30 kg. TSP approach guided with TEE and fluoroscopy was used for left atrium access.ResultsThe mean age, height, and body weight were 7.6 ± 1.9 years, 122.4 ± 9.3 cm and 24.0 ± 4.2 kg, respectively. Forty‐three children (50%) were male, 46 of 86 (53%) had manifest AP, 17 of 86 (20%) weighed less than 20 kg and in 24 of 86 children (28%) a three‐dimensional system (3DS) was used to reduce fluoroscopy time. The acute success rate was 98.8% (85/86), with a recurrence rate of 2.4% (2/85) in a mean follow‐up of 66.2 ± 42.7 (9.1‐184.2) months. The mean procedure time and fluoroscopy time were significantly lower for the 3DS group compared to the standard fluoroscopy group 131 ± 41 (55‐262) and 2.4 ± 1.5 (1‐6) minutes vs 164 ± 51 (62‐249) and 27 ± 13 (8‐77) minutes, P < 0.01 and P < 0.0001, respectively. There were no ablation‐related complications.ConclusionsRF ablation of left‐sided APs using TSP approach in small children had an excellent efficacy and safety profile. The use of 3DS significantly reduces the procedure and fluoroscopy time.

Intraoperative imaging and navigation for C1-C2 posterior fusion.

Background:Cervical axial spine fusion is challenging as the anatomy is extremely variable, and screw misplacement can lead to severe complications. C1 lateral mass screws and C2 pedicle screws are routinely placed under either fluoroscopic guidance or imaging-assisted navigation. Here, we compared the two for axial screw placement.Methods:We retrospectively evaluated patients’ treated from 2011–2016 utilizing the Harm’s procedure for C1-C2 screw fixation performed under either fluoroscopic guidance (nine patients) or image-assisted O-arm navigation (five patients). The groups had similar demographic and risk factors. Variables studied included operative time, estimated blood loss (EBL), accuracy of screw placement, screw reposition rates, and reoperation rates.Results:The mean EBL was 555CC and 260CC, respectively (not a significant difference) utilizing fluoroscopic versus O-arm navigation. Of interest, the mean surgical duration was 27 min longer in the O-arm versus fluoroscopy group (P = 0.03). Ten C2 pedicle screws were performed using O-arm navigation. Alternatively, as 9 of 18 C2 pedicles were considered “risky” for the placement of fluoroscopic-guided pedicle screws, laminar screws were utilized. Although the accuracy rate of C1 and C2 screw placement was higher for the navigated group, this finding was not significant. Similarly, despite complications involving two unacceptably placed screws from the fluoroscopic guidance group, there were no neurological sequelae.Conclusion:Axial cervical spine instrumentation is challenging. Utilization of Imaging-assisted navigation increases the accuracy and safety of screw placement.

Treatment of Post-traumatic Pediatric Ankle Varus Deformity with Physeal Bar Resection and Hemi-Epiphysiodesis.

Children presenting with partial physeal arrest and significant remaining growth may benefit from physeal bar resection, although the operation is a technique demanding procedure. This study evaluates the treatment of post-traumatic pediatric ankle varus deformity using physeal bar resection and hemi-epiphysiodesis with the assistance of two operative methods. Forty-five patients presenting with a distal tibial medial physeal bridge as well as ankle varus deformity following traumatic ankle physeal injury between 2009 and 2017 were followed. These patients were treated with physeal bar resection and hemi-epiphysiodesis, with the assistance of either fluoroscopy (10 cases) or intraoperative three-dimensional navigation (35 cases). Of the 45 cases, the median age was 9.0 years (range: 3-14 years) with 28 male and 17 female patients. The median of pre-operation ankle varus angle was 20 degrees (IQR 15-25) and 5 degrees (IQR 0-20) at the time of final follow up, representing a statistically significant difference (P<0.05). No differences were observed with regards to age, gender, and surgical history between effective group and ineffective group (P>0.05). The median of pre-operative ankle varus angles of the navigation and fluoroscopy groups were both 20 degrees (P>0.05). The median correction angle of the navigation and fluoroscopy groups was 10 and 15 degrees, respectively (P>0.05). Our results indicate that physeal bar resection and hemiepiphysiodesis are effective treatments for correcting ankle varus deformity due to traumatic medial physeal arrest of the distal tibia. We observe no difference in outcome between fluoroscopy group and three-dimensional navigation group during the procedures.

A Randomized Trial of Ultrasound- versus. Fluoroscopy-Guided Subclavian Vein Catheterization in Children with Hematologic Disease.

To compare the ultrasound- and fluoroscopy-guided subclavian vein catheterization in pediatric population with hematologic diseases. A randomized prospective study of subclavian vein catheterization in pediatric population with hematologic diseases was performed. After randomization, the patients were assigned to either ultrasound- or fluoroscopy-guided subclavian vein catheterization. The primary outcome was number of attempts at venous cannulation. Secondary outcomes included: catheterization success rate, fluoroscopy time, operation time, and surgical complications. There were 170 children enrolled between February 2017 and July 2018. There was no difference between the two groups with regard to the demographic data. Success within 3 attempts was achieved in 82 cases (82/87, 92.0%) in the ultrasound (US) group vs. 65 cases (65/83, 78.3%) in the fluoroscopy group (P = 0.002). The average operation time was 10(7) min in US group vs. 10(6) min in fluoroscopy group (P = 0.722). There were 3 complications in the US group, while there were 6 complications in the fluoroscopy group (P = 0.321). There were 4 catheter-related thrombosis (CRTs) found in the US group during follow-up, however there was no CRT in the fluoroscopy group (P = 0.121). Ultrasound-guided venous puncture is a more accurate method of subclavian vein catheterization. However, the catheter tip can be placed more precisely by fluoroscopy. Thus, combined ultrasound-and fluoroscopy-guided technology is more efficient in subclavian vein catheterization of children with hematologic disease.

Augmented reality and artificial intelligence-based navigation during percutaneous vertebroplasty: a pilot randomised clinical trial.

To assess technical feasibility, accuracy, safety and patient radiation exposure of a novel navigational tool integrating augmented reality (AR) and artificial intelligence (AI), during percutaneous vertebroplasty of patients with vertebral compression fractures (VCFs). This prospective parallel randomised open trial compared the trans-pedicular access phase of percutaneous vertebroplasty across two groups of 10 patients, electronically randomised, with symptomatic single-level VCFs. Trocar insertion was performed using AR/AI-guidance with motion compensation in Group A, and standard fluoroscopy in Group B. The primary endpoint was technical feasibility in Group A. Secondary outcomes included the comparison of Groups A and B in terms of accuracy of trocar placement (distance between planned/actual trajectory on sagittal/coronal fluoroscopic images); complications; time for trocar deployment; and radiation dose/fluoroscopy time. Technical feasibility in Group A was 100%. Accuracy in Group A was 1.68 ± 0.25mm (skin entry point), and 1.02 ± 0.26mm (trocar tip) in the sagittal plane, and 1.88 ± 0.28mm (skin entry point) and 0.86 ± 0.17mm (trocar tip) in the coronal plane, without any significant difference compared to Group B (p > 0.05). No complications were observed in the entire population. Time for trocar deployment was significantly longer in Group A (642 ± 210s) than in Group B (336 ± 60s; p = 0.001). Dose-area product and fluoroscopy time were significantly lower in Group A (182.6 ± 106.7mGy cm2 and 5.2 ± 2.6s) than in Group B (367.8 ± 184.7mGy cm2 and 10.4 ± 4.1s; p = 0.025 and 0.005), respectively. AR/AI-guided percutaneous vertebroplasty appears feasible, accurate and safe, and facilitates lower patient radiation exposure compared to standard fluoroscopic guidance. These slides can be retrieved under Electronic Supplementary Material.

Effects of physeal bar resection in treating post-traumatic distal radius partial physeal arrest

Objective: To evaluate the effects of treatment of post-traumatic distal radius partial physeal arrest with physeal bar resection. Methods: From February 2007 to November 2017, 11 children with distal radius physeal arrest received physeal bar resection in the Department of Pediatric Orthopedics, Beijing Jishuitan Hospital. There were 2 females and 9 males. The average age of the patients was (10.1±1.8) years (range,7-13 years). All cases had previous history of distal radius trauma. The average duration from the previous fracture to the physeal bar resection operation was (22.8±3.2) months (range,22 to 41 months). Clinical and radiological evidence of distal radius physeal arrest were suggested in all patients. A CT or MRI scan was performed preoperatively to assess the size of the physeal bridge. Inclusion criteria were patients with a physeal bridge<30% of the physeal area,and with at least 2 years of growth remaining. The physeal bar resection operation was performed with the assistance of either fluoroscopy (5 cases) or intraoperative three dimensional navigation (6 cases). After resection, the void was then filled with bone wax in all cases and distal ulnar epiphysiodesis was conducted in 5 cases. The mean follow-up duration was (3.7±1.6) years (range,1-9 years). The clinical examination data and X ray were obtained during the follow up. Results: Four cases obtained fully recovery from the operation and the deformity got fully correction. The X ray showed no bone bridge recurred. The deformity did not aggravate in 1 case. The deformity aggravated and subsequent osteotomy was conducted in the left 6 cases. Three cases in the navigation group obtained fully recovery. One case in the fluoroscopy group obtained fully recovery. Conclusions: The intraoperative three dimensional navigation can precisely locate the bone bridge. The physeal bar resection is an effective technique in some post-traumatic distal radius partial physeal arrest.

Intraoperative Computed Tomography–Guided Navigation for Pediatric Spine Patients Reduced Return to Operating Room for Screw Malposition Compared With Freehand/Fluoroscopic Techniques

PurposePlacement of pedicle screws can be performed using freehand/fluoroscopic technique or intraoperative computed tomography (CT)–guided navigation. We sought to compare screw malposition and return to operating room (OR) for pedicle screw malposition for screws placed with and without CT-guided navigation. MethodsThis study was a single-center retrospective comparative study. All patients younger than 18 years with minimum two-year follow-up who underwent pedicle screw instrumentation between 2009 and 2015 were included. Institutional review board approval was obtained and patient charts were reviewed for patient demographics and surgical outcomes. If available, incidental CTs following the index surgery were reviewed to assess screw position. ResultsA total of 217 patients underwent spinal instrumentation. Overall, 112 patients had pedicle screws placed using fluoroscopic guidance, whereas 105 patients had screws placed using low-dose intraoperative CT-guided navigation (O-arm; Medtronics). Of the total cohort, 107 (49.3%) patients had adolescent idiopathic scoliosis, and the remainder had neuromuscular, tumor, congenital, or other diagnoses. Patients in each group had a similar number of levels fused (fluoroscopic = 10.9 vs. CT navigation = 9.8, p = .06). There was no difference in total estimated blood loss (1,127 vs. 1,179 mL, p = .63) or in blood loss per level fused (133.7 vs. 146.6 mL, p = .47). Patients with screws placed using fluoroscopic guidance had a shorter total operative time (441 vs. 468 minutes, p = .04); however, there was no difference when controlling for number of levels fused (58.3 vs. 61.5 minutes/level, p = .63). Postoperative CTs were available in 51 patients representing 526 imaged screws, which showed a significantly higher rate of severely malpositioned (>4 mm) screws in the fluoroscopic group than the CT navigation group (3.3% vs. 1.0%, p = .027). There was a 3.6% rate of return to OR for pedicle screw malposition in the freehand/fluoroscopic group compared with 0% in the CT-guided navigation group (p = .048). Including patients with less than two-year follow-up (169 fluoroscopy, 220 CT guidance) also found higher rates of screw malposition (13.5% vs. 7.1%, p = .004), severe screw malposition (3.0% vs. 0.50%, p = .04), and return to OR due to screw malposition (2.4% vs. 0%, p = .02) in patients with screws placed using fluoroscopic guidance. ConclusionPatients with pedicle screws placed with CT-guided navigation had a lower rate of severely malpositioned screws and unplanned returns to the OR. There was no significant difference in blood loss or operative time when controlling for number of levels fused. SignificanceIn the era of health care “never-events,” return to OR for screw malposition could certainly be deemed unacceptable. Use of intraoperative CT-guided navigation thus far eliminated return to OR for screw malposition in a complex cohort of pediatric spinal deformity patients, without measurable increase in operative time or blood loss.

Intracardiac echocardiography versus fluoroscopy for endovascular and endocardial catheter navigation during cryo-ablation of the slow pathway in AVNRT patients

BackgroundA new zero-fluoroscopy technique for electrophysiology catheter navigation relying on intracardiac echocardiography (ICE) has been recently reported (Ice&ICE trial). We investigated potential differences in efficacy, safety or procedural performance between conventional fluoroscopy- and ICE-guided cryothermal ablation (CA) in symptomatic AVNRT patients.MethodsClinical and electrophysiological data of AVNRT patients included in the Ice&ICE trial (22 patients, 16 females; =zero-fluoroscopy group) were compared to those of consecutive AVNRT patients, who underwent fluoroscopy-guided CA (25 patients, 17 females; = fluoroscopy group) during the last 2 years in our institution.ResultsSlow pathway ablation or modulation was successful in all patients. Fluoroscopy time and radiation dose in the fluoroscopy group were 11.2 ± 9.0 min and 20.3 ± 16.2Gycm2, whereas no fluoroscopy was used in the opposite group (p < 0.001, respectively). EPS duration was not different between the groups (zero-fluoroscopy:101.6 ± 40.2 min, fluoroscopy:99.4 ± 37.2 min, p = n.s.). Catheter placement time was significantly shorter in the fluoroscopy group (2.2 ± 1.6 min vs. 12.0 ± 7.5 min, p < 0.05), whereas cryo-application duration (from the first cryo-mapping to the last CA) was significantly shorter in the zero-fluoroscopy group (27.5 ± 37.0 min vs. 38.1 ± 33.9 min, p < 0.05). Mean cryo-mapping and CA applications were numerically lower in the zero-fluoroscopy group (CM:7.5 ± 5.7 vs. 8.8 ± 6.2; CA:3.1 ± 1.7 vs. 3.2 ± 2.0, p = n.s.). No major adverse events occurred in both groups. After 15.0 ± 4.2 months, arrhythmia recurrence was not different between the groups (4.5% vs. 8.0%, p = n.s.).ConclusionsZero-fluoroscopy ICE-guided EP catheter navigation shows comparable efficacy and safety to fluoroscopic guidance during CA in AVNRT patients. ICE visualization of catheters and endocardial structures within the triangle of Koch shortens the cryo-application duration, though time needed for catheter placement is longer, when compared with conventional fluoroscopic guidance, which results in similar mean EPS duration with both navigation techniques.Trial registration(German Clinical Trials Register ID: DRKS00011360; Registration Date 14.12.2016)

Comparative study of sacroiliac screw placement guided by 3D-printed template technology and X-ray fluoroscopy

ObjectiveTo compare the clinical effect of 3D-printed template technology with X-ray fluoroscopy in assisting surgery for sacroiliac screws placement.DesignInstitutional review board-approved retrospective analysis.PatientsThe clinical data of 31 cases of sacroiliac complex injury between January 2015 and December 2016 were analyzed. There were 16 patients, males 11 and females 5, who underwent surgery assisted by 3D-printed template in template group, and that of contemporaneous 15 patients, males 11 and females 4, who underwent traditional surgery were gathered as fluoroscopy group. All those patients were followed up for more than 6 months.Main outcome measuresThe operation time and X-ray fluoroscopy times for each screw placement, and the Matta and Majeed score were analyzed and the difference between the two group was tested.ResultsAll cases were followed up for 6–20 months, average 11.4 ± 0.6 months. In template group, 19 screws were implanted. Each screw spent 25–38 min, average 27.2 ± 5.3 min, and need 2–5 times fluoroscopy, average 2.7 ± 0.5. The fracture reduction quality was evaluated by Matta score scale: excellent 10, well 4, fair 2, good rate 87.5%; and pelvic function were evaluated by Majeed score scale: excellent 11, well 3, fair 2, and good rate 87.5%. In fluoroscopy group, 17 screws were implanted. Each screw spent 45–70 min, average 60.3 ± 5.8 min, and needs 11–23 times fluoroscopy, average 15.4 ± 3.5. The fracture reduction quality was evaluated by Matta score scale: excellent 7, well 6, fair 2, and good rate 86.7%; and pelvic function was evaluated by Majeed score scale: excellent 6, well 6, fair 3, and good rate 80.0%. The difference in operation time, X-ray fluoroscopy times between template group and fluoroscopy group had statistical significance. But the Matta and Majeed score had no difference between two groups.ConclusionCompared with traditional surgery, 3D-printed template technology-assisted surgery for sacroiliac screws placement in sacroiliac complex injury patients possesses advantage such as shortened operation time and reduced X-ray exposure times. This technology improves the safety profile of this operation and should be further studied in future clinical applications.

Three-dimensional navigation (O-arm) versus fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone curette: A retrospective comparative study.

Three-dimensional intraoperative navigation (O-arm) has been used for many years in spinal surgeries and has significantly improved its precision and safety. This retrospective study compared the efficacy and safety of spinal cord decompression surgeries performed with O-arm navigation and fluoroscopy. The clinical data of 56 patients with thoracic spinal stenosis treated from March 2015 to April 2017 were retrospectively analyzed. Spinal decompression was performed with O-arm navigation and ultrasonic bone curette in 29 patients, and with ultrasonic bone curette and fluoroscopy in 27 patients. Patients were followed-up at postoperative 1 month, 3 months, and the last clinic visit. The neurologic functions were assessed using the Japanese Orthopaedic Association (JOA) Back Pain Evaluation Questionnaire. The accuracy of screw placement was examined using three-dimensional computed tomography (CT) on postoperative day 5. There was no significant difference in the incidences of intraoperative dural tear, nerve root injury, and spinal cord injury between the two groups. The two groups showed no significant difference in postoperative JOA scores (P > .05). The O-arm navigation group had significantly higher screw placement accuracy than the fluoroscopy group (P < .05). O-arm navigation is superior to fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone curette in terms of screw placement accuracy. However, the two surgical modes have similar rates of intraoperative complications and postoperative neurologic functions.

Radiation-free flexible ureteroscopy for kidney stone treatment

ABSTRACTObjectives: To evaluate the safety and effectiveness of flexible ureterorenoscopy (fURS) with holmium laser lithotripsy for treating kidney stones without fluoroscopy as method of best practice for patients and endourologists.Patients and Methods: All patients treated for kidney stones by fURS with holmium laser lithotripsy from February 2016 to February 2017 were retrospectively evaluated. The patients’ demographic characteristics, stone features (size, number, and location), surgical variables (use of fluoroscopy, operative and fluoroscopy time), complications, and success rate (employing stone-free rate [SFR]), were included in the analysis.Results: In all, 100 patients met the inclusion criteria: 33 fURS were performed under fluoroscopy (Group 1) and 67 without it (Group 2). The mean operating time was 94.33 vs 98.29 min (P = 0.888), respectively. The mean stone volume was 78.5 vs 82.4 mL (P = 0.885), respectively. The SFR was 63.6% and 64.2% (P = 0.771), the perioperative complications rate was 18.2% vs 11.9% (P = 0.285), and the postoperative complications rate was 24.2% and 10.4%, in groups 1 and 2 respectively (P = 0.174).Conclusions: fURS with holmium laser lithotripsy without fluoroscopy was a feasible and safe treatment for kidney stones. There was no difference between the use of fluoroscopy or not regarding complications or SFR. Thus, we can reduce the risks of radiation exposure to patients and medical staff whilst maintaining surgical success. However, multicentre randomised controlled studies are necessary to evaluate fluoroless URS further and to confirm our present results.Abbreviations: PTFE: polytetrafluoroethylene; SFR: stone-free rate; (f)URS: (flexible) ureterorenoscopy/ureterorenoscopies; US: ultrasonography

Accuracy of Robot-Assisted Percutaneous Pedicle Screw Placement for Treatment of Lumbar Spondylolisthesis: A Comparative Cohort Study.

BackgroundWith the in-depth development of minimally invasive spine surgery in recent years, robot- and computer-assisted technologies have been increasingly used and successfully applied to spinal surgery.Material/MethodsWe performed a retrospective analysis of 60 patients with grade I or II lumbar spondylolisthesis who underwent minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) from January 2017 to December 2017. A robot-assisted surgical system was used in 30 patients for pedicle screw placement. The other 30 patients underwent fluoroscopy-guided percutaneous pedicle screw placement.ResultsThere were 130 screws placed under fluoroscopic guidance, with 26.2% penetration of the pedicle wall. There were 130 screws placed in robotic-assisted surgery, with 6.2% penetration of the pedicle wall. Severe screw deviation (Neo grade III) was identified in 4 screws in the fluoroscopy-guided group, while no severe deviation was noted in the robot-assisted group. In the fluoroscopic group, 15.6% of screws penetrated the superior articular process, and 2.1% screws had severe complications (Babu grade III). However, only 5.1% of screws in the robot-assisted group had severe complications. The mean screw insertion angle was significantly greater in the robot-assisted group than in the fluoroscopy-guided group (23.8±6.1° vs. 18.4±7.2°, P=0.017).ConclusionsCompared to fluoroscopy-guided percutaneous pedicle screw placement, robot-assisted percutaneous pedicle screw placement has the following advantages: greater accuracy, lower incidences of screw penetration of the pedicle wall and invasion of the facet joints, and better screw insertion angle. Combined with MIS-TLIF, robot-assisted percutaneous pedicle screw placement is an effective minimally invasive treatment for lumbar spondylolisthesis.