Diagnostic reference levels for pediatric fluoroscopy procedures: A systematic review.

Fluoroscopically guided jejunal tube placement via percutaneous endoscopic gastrostomy (PEG-J) provides minimally invasive post-pyloric access in children. Limited data exist regarding routine application and procedural risks. To evaluate the safety and technical success of PEG-J in pediatric patients, performed without general anesthesia or sedation. All pediatric cases of fluoroscopically guided PEG-J procedures performed between 2011 and 2025 were included. Fluoroscopic images were reviewed to determine the final position of the tube tip. Technical success, complications, anatomical variants, and tube patency were assessed. Fluoroscopy time and dose area product (DAP) were documented. A total of 126 PEG-J procedures in 60 children (36 males) were analyzed. The technical success rate was 85% (107/126) with final tube tip placement in the jejunum in 88 cases (82%) and in the duodenum in 19 cases (18%). Nineteen procedures (15%) were unsuccessful, including six with documented anatomical causes (steep vertical duodenal entry, n=2; malrotation, hiatus hernia, hooked stomach in superior mesenteric artery syndrome, steep take-off of the jejunum with kinking of the tube at the ligament of Treitz, n=1 each) and 13 without documented reasons. The median fluoroscopy time was 5min 24s (range, 2s-37min), at a frame rate of 0.5 frames per second. The median DAP was 6.1cGy·cm2 (range, 0.08-343cGy·cm2). Fluoroscopically guided PEG-J placement is a safe and effective procedure in pediatric patients, with high technical success and low radiation exposure.

The "Schöttle point" is an important anatomical landmark in medial patellofemoral ligament (MPFL) reconstruction. This study aimed to observe the relationship of Schöttle point and distal femoral physis (DFP) using three-dimensionl (3D) computed tomography (CT), given the existing controversy and potential risks of physeal injury during surgery. A retrospective analysis of 118 knee CT scans from 88 patients (aged 6-16 years) was conducted. Using RadiAnt Viewer, the two-dimensional (2D) Digitally Radiograph (DR) and 3D renderings were reconstructed. The Schöttle point was identified, and its position relative to the DFP was assessed on both 2D and 3D images. Key distances, including the vertical Schöttle point-to-DFP distance, were measured on 3D reconstructions. Statistical analyses included correlation and reliability tests. A critical discrepancy was found: on 3D renderings, the Schöttle point was consistently distal to the DFP in all knees. Conversely, 2D-DR showed its position as proximal or at the physis in 100% of cases. The mean vertical distance from Schöttle point to DFP on 3D renderings was 6.1 ± 1.9 mm, showing a strong positive correlation with patient age (p < 0.01) that plateaued after 12 years. Notably, the methods of the Schöttle point do not seem to fit all five knees from patients under 8-year-old. Measurements demonstrated excellent reliability (ICC > 0.75). The Schöttle point's cortical position is consistently distal to the DFP in paediatric knees on 3D assessment, a relationship often different from 2D radiographs. Crucially, surgeons must respect the U-shaped 3D morphology of the physis when planning tunnel trajectory to avoid physeal damage. The distance from Schöttle point to the DFP increases with age. Intraoperatively, the position can be controlled using fluoroscopic 2D images combined with palpation of bony landmarks, though 3D planning is recommended for precision during paediatric MPFL reconstruction. Level of Evidence Level III, cross-sectional study.

Objective: Variable angle locking plates were developed to allow flexible screw trajectories and broader fixation within the humeral head in proximal humerus fractures, where fixation failure remains a common challenge. Whether this theoretical advantage is utilized in clinical practice remains unclear. Methods: This retrospective radiographic study evaluated 43 patients treated with locking plate fixation for proximal humerus fractures between 2015 and 2023. Eighteen patients received variable angle plates and 25 fixed angle plates. Screw trajectories were assessed on early postoperative radiographs and intraoperative fluoroscopy. Vertical screw distribution was measured as the percentage of anatomical neck coverage in the coronal plane, and axial screw spread was defined as the angle between the 2 most divergent screws on lateral fluoroscopic images. Results: Screws placed through variable angle plates covered a smaller proportion of the anatomical neck compared with fixed angle constructs. In the axial plane, fixed angle plates demonstrated a mean screw divergence of 40°, whereas variable angle plates showed significantly narrower spread, with a mean divergence of 15.4° (P &lt; .001). Variable angle screws were therefore placed in a more convergent configuration despite the availability of angular freedom. Conclusion: Despite their intended design, variable angle proximal humerus plates demonstrated a consistent tendency toward convergent screw placement in clinical practice, resulting in reduced humeral head coverage compared with fixed angle constructs. Further clinical studies are required to determine whether this radiographic mismatch has clinical relevance and whether deliberate screw divergence influences fixation durability and outcomes. Cite this article as: Birsel O, Güllü B, Eren İ, Demirhan M. Trend of convergent screw placement in variable angle proximal humerus plates. Cerrahpaşa Med J. 2026, 50, 0116, doi:10.5152/cjm.2026.25116.

A pilot morphometric analysis of lumbar vertebrae to identify fluoroscopic biomarkers

Dynamic changes in the moment arm of the Achilles tendon during weight bearing conditions measured by dual fluoroscopy imaging system.

Impacts of malalignment in medial compartment knee osteoarthritis on the patellofemoral joint: A quantitative analysis during staircase motion.

Scapholunate Ligament Reconstruction with Suture Augmentation: a Biomechanical Analysis.

Purpose: Radiation exposure from intraoperative fluoroscopy is routinely encountered in orthopedic procedures, especially during distal radius fracture fixation. Prolonged exposure to high-dose radiation is a known risk factor for genetic mutations. This study presents a simple, alternative mechanical targeting device using a plummet that functions as a laser aimer. Methods: A prospective randomized controlled trial was conducted at a single institution involving 42 consecutive patients who underwent locked plate fixation for distal radius fractures and were randomized into two groups. One group underwent fluoroscopic imaging using a plummet as the aiming device, whereas the other group underwent imaging without an aimer. The radiation exposure time, dose, and fluoroscopy accuracy were recorded and analyzed. Results: A total of 42 patients were enrolled, with 21 assigned to the Plummet group and 21 to the Control group. Demographic data and fracture patterns were comparable between the groups. Compared to the Control group, the Plummet group required significantly fewer fluoroscopic images (8.38 vs. 21.86) and demonstrated a higher accuracy of fluoroscopy (99.21% vs. 67.53%). Radiation exposure was also lower in the Plummet group (3.78 vs. 9.98 µSv), with a shorter ionizing radiation exposure time (0.05 vs. 0.13 min). Operative time was also reduced in the Plummet group (51.52 vs. 60.81 min). Conclusions: Compared to the conventional method, the use of a plummet as an aiming device significantly reduced the number of fluoroscopic images, radiation exposure, and operative time, while improving the accuracy of fluoroscopy.

Simulator-based training addresses a pressing need to move surgical skill acquisition from the operating room to the laboratory, reducing patient risk associated with traditional trial-and-error training methods. The Core Requisites of Orthopedic Wire Navigation Skills (CROWNS) curriculum employs a hybrid reality simulator to teach surgeons the foundational skill of placing a guidewire in bone via fluoroscopic imaging. Simulator-based training has already been shown to improve subsequent operating room performance, but objective benchmarks to assess skill proficiency are lacking. The objective of this study was to measure and compare expert and novice performance on a simulated hip wire navigation task as a basis to define candidate proficiency training benchmarks. This study was designed as an experimental assessment of a surgical simulation platform to differentiate between skill levels during a proctored examination. In all, 113 surgeons participated, including 68 orthopaedic residents (novices) and 45 experts (28 Orthopaedic Trauma Association fellows and 17 practicing orthopaedic surgeons). To achieve the primary objective of measuring and comparing expert and novice performance, all participants performed a simulated hip wire navigation task replicating guide wire placement for intertrochanteric fracture fixation. Experts completed three simulated patient scenarios: one represented a straightforward case with clear imaging and a typical femoral neck-shaft angle (∼ 135°), another required a steeper guidewire trajectory to match an increased neck-shaft angle, and another involved a slightly malreduced fracture with an imperfect lateral view, requiring greater judgment to determine appropriate wire placement. Novices completed only the straightforward case scenario. Performance metrics included tip-apex distance (TAD), fluoroscopic image count, time, decision errors, the angle of off-target adjustments, and the previously reported Image-based Decision Error Analysis (IDEA) composite score. The IDEA score is normalized, meaning that a participant's score reflects the number of SDs above or below the mean performance across a large resident cohort. Assuming a normal distribution of scores, 95% of participants would be expected to score between -2 and +2. Higher values indicate better performance generally associated with more surgical experience. The score combines three normalized components-TAD, angle error, and decision errors-where lower TAD and smaller or fewer errors yield a more positive score. Statistical analyses compared novice and expert cohorts to help inform proficiency benchmark recommendations. The expert cohort's simulator-based IDEA scores were then compared with prior intraoperative IDEA scores from residents. The expert cohort completed all three simulated patient scenarios with a mean ± SD time of 117 ± 60 seconds, using 17 ± 8 images, and achieving a TAD of 13 ± 5 mm. The expert cohort had 5 ± 4 decision errors, angle errors of 1.4° ± 1.8°, and an IDEA score of 0.65 ± 0.4. The novice cohort completed their single patient scenario with a time of 207 ± 88 seconds, using 22 ± 10 images, and achieving a TAD of 20 ± 7 mm. The novice cohort had 14 ± 7 decision errors, angle errors of 3.2° ± 3.0°, and an IDEA score of -0.21 ± 0.7. When comparing the performance of the expert and novice cohorts in the single shared case scenario, the expert cohort achieved a substantially higher IDEA score (0.62 ± 0.3 and -0.21 ± 0.7, respectively, mean difference 0.83 [95% confidence interval 0.58 to 1.07]; p < 0.001). Based on prior research linking simulator performance to actual surgical experience, the expert IDEA mean score of 0.65 was roughly comparable to a performance expected in novices after their first 11 completed wire navigation surgical cases. An IDEA score of 0.5 is proposed as a balanced proficiency benchmark, achieved by 75% of experts but only 13% of novices. The CROWNS simulator and IDEA composite score reliably distinguished expert from novice performance, underscoring the need for deliberate practice and targeted feedback to close the novice-expert gap. A benchmark IDEA score of 0.5 offers a rigorous yet attainable goal for residents, representing readiness for safe and efficient operating room participation. Objective, simulation-based proficiency standards-such as attaining an IDEA score of 0.5 for hip fracture pinning-can guide competency-based progression, ensuring that residents achieve the technical skill required for safe operating room performance. Future research should evaluate how such benchmarks translate to real-world outcomes and whether they can be optimized to further improve surgical training and patient safety.

Minimally-invasive percutaneous treatment has become the most popular and effective method for the treatment of acetabular fractures. The aim of this study was to investigate the safety and efficacy of minimally-invasive percutaneous treatment of adult acetabular fractures with the titanium elastic nail system. 12 patients with acetabular fractures were referred to us from March 2020 to June 2020, including 8 males and 4 females. The life-threatening shock and severe combined injury were treated first. The acetabular fractures (anterior and double-column fractures) were all treated with closed reduction and minimally-invasive elastic titanium nail intramedullary fixation. Intraoperative C-arm and O-arm fluoroscopy were used to determine the reduction of fractures and the location of elastic titanium nail in the bone channel. Postoperative CT was used to measure and evaluate the reduction of fracture and the position of elastic titanium nail. Through closed reduction and minimally-invasive incision, the acetabular fractures could be safely fixed by placing elastic titanium nail in the osseous medullary cavity channels of acetabulum. The placement time of each elastic titanium nail was 15-45 minutes, with an average of 19.6 minutes. The frequency of fluoroscopy imaging of each elastic titanium nail was 4-16 times, with an average of 8 times. Postoperative wounds of the patients were all healed in the first stage, without any occurrence of complications such as nerve, blood vessel and important tissue structure injury. The patients recovered quickly after the operation and could perform functional exercises in the early stage. Elastic intramedullary nail system can be used for the minimally-invasive treatment of adult acetabular fractures, with less blood loss, less cost, and fewer incision complications. This is a promising new technique.

This study aimed to quantitatively evaluate radiation doses delivered to radiosensitive thoracic and cervical organs during fluoroscopy-guided central venous port (CVP) catheter placement using a standardized experimental setup to identify the most exposed anatomical regions. An Alderson Rando anthropomorphic phantom equipped with calibrated MTS-100 thermoluminescent dosimeters (TLDs) was employed to simulate a typical CVP fluoroscopic procedure. The setup used a Siemens Artis Zee C-arm fluoroscopy system with a total active exposure time of 8 min, replicating clinical practice. Absorbed dose measurements were obtained from 14 organ sites, including lungs, thyroid, spinal cord, and upper airway structures. The highest radiation doses were observed in thoracic organs, with measured values of 7.84 ± 0.28 mGy for the right middle lung, 5.23 ± 0.40 mGy for the thoracic spinal cord, and 3.91 ± 1.47 mGy for the right lung apex. The thyroid received moderate exposure, recording 1.48 ± 0.35 mGy (right lobe) and 1.41 ± 0.68 mGy (left lobe). In contrast, distant organs such as the pituitary gland and ethmoid sinus exhibited negligible absorbed doses (< 0.03mGy). Fluoroscopic CVP placement results in substantial localized radiation exposure, particularly to the lungs and thyroid. Quantitative organ dose mapping using an anthropomorphic phantom provides a valuable reference for optimizing patient safety protocols and minimizing radiation exposure during interventional procedures.

To compare technical success, procedural metrics, and complication patterns of percutaneous transhepatic biliary drainage (PTBD) in dilated versus nondilated biliary systems. This retrospective single-center study included 440 PTBD procedures performed in 388 patients between October 2022 and June 2025. Patients undergoing concomitant biliary interventions or repeat attempts within 7 days were excluded. Biliary ductal status was determined using preprocedural CT and intraprocedural ultrasonography, with dilatation defined as a largest visible intrahepatic bile duct diameter > 2mm. Procedural time was subdivided into an access phase (T1 time: from the first fluoroscopic image to cholangiography) and a catheter-placement phase (T2 time: from cholangiography to final catheter placement). Technical success, total procedure time, T1 and T2 times, fluoroscopy time, radiation dose, and complications graded according to CIRSE criteria were recorded. Comparative analyses were performed between dilated and nondilated ducts and subgroup evaluation was conducted within nondilated ducts for bile leakage versus other indications. PTBD was performed in 318 dilated and 122 nondilated ducts. Technical success was significantly lower in nondilated ducts (89.3% vs. 99.7%, p < 0.001). Nondilated procedures demonstrated prolonged total procedure time, longer T1 time, and greater fluoroscopy time and radiation exposure (all p < 0.001), while T2 duration remained similar. Overall complication rates were comparable; however, bleeding complications were more frequent in nondilated ducts (6.6% vs. 1.3%, p = 0.005). Cholangitis predominantly occurred in dilated ducts (6.0% vs. 0.8%, p = 0.019). Nondilated ducts pose greater technical difficulty and procedural burden during PTBD, reflected by lower success rates and increased bleeding risk, whereas dilated ducts have a higher propensity for cholangitis. Recognizing ductal status is essential for procedural planning and risk stratification.

This study aimed to investigate the horizontal positioning (HP) technique for the precise lateral insertion of the helical blade guide pin during proximal femoral nail antirotation (PFNA) procedures for elderly osteoporotic patients. This retrospective study involved elderly osteoporotic patients with femoral intertrochanteric fractures treated at Tianjin Union Medical Center from January to December 2024. Patients were categorized into the HP group and the traditional true lateral view (TLV) group. The analyzed variables included fracture classification, horizontal anteversion angle (HAA), success rate of one-time lateral pin placement (SR-OLPP), pin insertion time, frequency of intraoperative lateral fluoroscopy images (FILFI), Parker's ratio index, lag screw placement, tip-apex distance (TAD), and reduction quality. A total of 86 patients participated in the study (HP group: n = 46; TLV group: n = 40), with no significant differences in baseline characteristics between the groups. The HP group demonstrated a significantly shorter pin insertion time compared to the TLV group [1 (1-3) vs. 3 (2-5) min, p < 0.001] and required fewer intraoperative lateral fluoroscopy images [1 (1-3) vs. 3 (2-6), p < 0.001]. The horizontal anteversion angle in the HP group was 6.4 ± 6.3°. The success rate of one-time lateral pin placement was higher in the HP group (95.7 vs. 85.0%, p = 0.138). No significant differences were found between two groups concerning reduction quality or spiral blade position and short-term post-operative complications. HP technology may enhance surgical efficiency and reduce radiation exposure while maintaining surgical safety and the accuracy of nail placement.

Objective: Cervical facet joints are prominent sources of chronic neck pain. This single-center retrospective cohort study compared ultrasound (US)-guided and fluoroscopy (FL)-guided cervical medial branch procedures at the C3-C6 levels in terms of technical success and tested for non-inferiority (NI). Methods: Between March 2022 and July 2025, 224 procedures performed at the Adana City Training and Research Hospital, Department of Algology (US, n = 104; FL, n = 120), were analyzed. The primary endpoint was technical success. Secondary endpoints included procedure duration; complications; pain intensity, measured using the Visual Analog Scale (VAS); functional outcomes, assessed with the Neck Disability Index (NDI) at 1, 3, 6, and 12 months; and radiation exposure in the FL group. Propensity score weighting was applied to reduce confounding. The NI margin for technical success was set at -5 percentage points, with α = 0.025. Results: The technical success rates were similar (US: 90.4%, FL: 90.8%; difference: -0.4%, 95% CI: -8.1 to 7.2), but non-inferiority was not statistically achieved (power ≈ 72%). Procedure time was significantly shorter in the ultrasound-guided group compared with the fluoroscopy-guided group (mean difference -5.2 min; 95% CI: -7.5 to -2.9; p < 0.001). No major complications occurred. Both groups demonstrated sustained improvement over 12 months, with VAS scores decreasing from 7.4 at baseline to 4.0 at 12 months and NDI scores decreasing from 41.3 to 29.2. No statistically significant between-group differences were observed for pain intensity (VAS) at any follow-up time point (all p > 0.05). Similarly, functional outcomes (NDI) did not differ significantly between the ultrasound- and fluoroscopy-guided groups throughout follow-up (all p > 0.05). Exploratory analyses using minimum clinically important difference (MCID) thresholds supported the clinical non-inferiority of US. In the FL group, the mean fluoroscopy time was 2.28 min with low radiation doses. Conclusions: Although NI was not statistically confirmed for technical success, US achieved comparable outcomes to FL with shorter procedure times and without radiation exposure. Both modalities provided similar long-term pain relief and functional improvement. US can be considered a safe and effective alternative in experienced hands, but larger multicenter prospective NI trials are needed to confirm these findings.

Background:Weightbearing foot and ankle radiographs are essential because skeletal geometry changes under load. Radiographic measurements, which guide management decisions, have been validated using weightbearing radiographs. Simulation of weightbearing intraoperatively would be ideal and may improve the accuracy of deformity correction in foot and ankle surgery. This study aims to validate the accuracy of angular measurements on intraoperative simulated weightbearing fluoroscopic foot images.Methods:A prospective study of 50 patients with a mean age of 51.3 years undergoing elective foot surgery at a single institution was performed. A simulation of weightbearing was performed intraoperatively and fluoroscopic anteroposterior and lateral images were obtained. Six angular measurements were performed on the standard preoperative weightbearing radiographs and compared to the intraoperative simulated weightbearing fluoroscopic images, by 4 researchers at 2 intervals.Results:The mean differences for the hallux valgus angle (HVA), intermetatarsal angle (IMA), interphalangeal angle (IPA), 4-5 intermetatarsal angle (4-5 IMA), calcaneal pitch (CP), and talocalcaneal angle (TCA) were +0.02, −1.79, +1.13, −0.01, +4.80, and −1.41 degrees, respectively. Of the anteroposterior and lateral measurements, the HVA, IPA, 4-5 IMA, and TCA showed no statistically significant mean difference (paired t test), and inter- and intraobserver reliability was good to excellent. The IMA and CP showed a mean difference that was statistically significant; however, this mean difference was clinically negligible (IMA: −1.79 ± 1.68 degrees; CP: 4.8 ± 3.4 degrees). A good inter- and intraobserver reliability was found between researchers. Regression analyses showed strong correlations for the HVA, IMA, 4-5 IMA, and CP and fair correlations for the TCA and IPA.Conclusion:The study suggests the technique we use for intraoperative simulated weightbearing fluoroscopic imaging correlates with standard preoperative weightbearing foot radiographs and may facilitate a more accurate, real time assessment of alignment during foot deformity correction surgery.Level of Evidence:Level II, diagnostic.

Meniscus root tears, if untreated, can lead to rapid osteoarthritic changes. Effective repairs are essential to maintain meniscal function and prevent degeneration. This study aimed to evaluate the integrity of medial meniscus (MM) root repairs performed using an inlay transosseous single-tunnel repair technique. It was hypothesized that such repairs could withstand physiological cyclic weightbearing in full extension. Controlled laboratory study. Fifteen fresh-frozen cadaveric knee specimens (mean age, 67 ± 14 years) with intact collateral ligaments, cruciate ligaments, and meniscocapsular attachments were used. Diagnostic arthroscopy confirmed MM integrity in 11 specimens, which then underwent root detachment and repair using a transosseous single-tunnel technique. Metallic tracers were placed into the medial tibial spines and posterior horns of the medial menisci. Specimens were loaded in full extension using a tensile testing machine under 4 conditions: intact, cut, repaired, and repaired after cyclic loading (1700 N for 250 cycles). Fluoroscopic imaging, performed with standardized, reproducible positioning, documented meniscal displacement with known resolution. ImageJ software was used to calculate displacement normalized to tibial plateau width. Repair integrity after cyclic loading was assessed by arthroscopic inspection. All specimens showed intact MM root repairs after cyclic loading. Significant meniscal displacement was observed between intact and cut states (P = .044), intact and repaired states (P = .020), and intact and repaired-cycled states (P = .036). No significant difference was found between repaired and cut or between repaired and repaired-cycled states (P > .05). Repairs did not catastrophically fail but demonstrated significant plastic deformation. MM root repairs using the transosseous single-tunnel technique do not withstand simulated physiological weightbearing in full extension and demonstrate meniscal displacement similar to that of the unrepaired (cut) state in a cadaveric model. This study suggests that MM root repairs with this technique allow unacceptable displacement under physiological loads. These results provide insight into the biomechanical performance of meniscus root repairs and underscore the importance of establishing appropriate postoperative weightbearing protocols.

Cadaveric validation study. To evaluate the accuracy of a structured four-step ultrasound (US)-guided workflow for lumbar spinal level identification (SLI) using cadaveric specimens. Despite the routine use of fluoroscopic verification, wrong-level spinal surgery continues to be a documented and concerning complication. Fluoroscopy exposes patients and staff to ionizing radiation and requires specialized personnel and infrastructure. US has been utilized for SLI in obstetric and anesthetic applications but remains underexplored in surgical workflows. Ten fresh-frozen cadavers underwent US imaging to identify lumbar levels. A newly developed four-step protocol was employed: (1) Midline localization, (2) Sacral surface tracing, (3) S1-Superior articular process (SAP) recognition, (4) Interlaminar space enumeration. Five spinal needles were placed under US guidance in each specimen (L1-2 through L5-S1), with one needle per level. Fluoroscopic imaging was then used to confirm needle placement accuracy. A level was defined as misidentified if the projected trajectory from the needle tip violated predefined radiographic boundaries. A total of 50 lumbar levels were assessed across ten cadaveric specimens, with 25 procedures performed from the right side and 25 from the left. Fluoroscopic validation demonstrated accurate level identification in 49/50 cases, yielding an accuracy rate of 98%. The single misidentification occurred at the L5-S1 level during the third step of the workflow, where the S1 SAP was erroneously interpreted as the L5 inferior articular process. No systematic error patterns were observed, and the four-step protocol proved reproducible across specimens. This cadaveric feasibility study establishes a high accuracy of US-guided lumbar level identification. A structured and reproducible workflow for level localization was established, integrating a novel four-step protocol. These findings represent a first step toward a radiation-free alternative for preoperative lumbar level verification in spinal surgery. Further investigations are warranted to validate these results in clinical settings.

Background:Distal medial collateral ligament (MCL) injuries are less common and have worse healing potential than proximal MCL injuries. The purpose of this video is to demonstrate the surgical technique of distal MCL repair with suture augmentation.Indications:The patient is a 17-year-old man who sustained a distal MCL injury and medial meniscocapsular junction tear while playing soccer. He was indicated for surgical management due to a complete distal MCL tear with symptomatic instability and concomitant medial meniscocapsular injury.Technique Description:The patient was placed in a supine position, and the bilateral knee was examined. Arthroscopic evaluation demonstrated a medial meniscocapsular junction tear, which was treated with a series of all-inside, horizontal mattress sutures. The proximal attachment of the MCL was identified proximally and posteriorly to the medial epicondyle under fluoroscopic imaging. The deep and superficial MCL attachments on the tibia were marked 1 and 6 cm distal to the medial joint line, respectively. After dissection of the pes anserine and distal MCL, a 1.8-mm knotless, all-suture anchor was inserted into the proximal attachment site of the MCL, and a fiber tape was passed through the anchor and folded to create 2 limbs. Two 1.8-mm knotless, all-suture anchors were inserted anterior and posterior to the native deep MCL, creating a mattress construct. The 2 limbs of the fiber tape were passed under the pes anserine and secured to the tibia with a 4.75-mm biocomposite knotless anchor with the knee positioned in neutral rotation, 30° of knee flexion, and varus stress.Results:The patient presented had full range of motion and stability compared with the contralateral extremity at 3 months postoperatively. Strength testing at 6 months demonstrated >95% strength in his proximal thigh musculature compared with the contralateral extremity. He was returned to sports without limitations at 6 months postoperatively.Discussion/Conclusion:Complete distal MCL injuries with instability and concomitant meniscal tears may be indicated for surgery, and arthroscopic medial meniscal repair with distal MCL repair with suture augmentation is a viable and replicable surgical treatment for this condition.Patient Consent Disclosure Statement:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Valvular heart disease (VHD) remains significantly underdiagnosed and undertreated. This review examines an artificial intelligence (AI)-enhanced 'spoke-hub-node' care model designed to improve the early detection, risk stratification, and treatment of VHD. In this model, AI tools-such as automated ECG interpretation, digital stethoscopes, and point-of-care ultrasound-facilitate decentralized screening and referral for cardiac imaging at the community level. During the transition from outpatient settings to tertiary care centres, AI-integrated echocardiography, cardiac tomography, and magnetic resonance imaging facilitate advanced diagnostic evaluation and inform procedural planning. We review emerging innovations that can enhance this model of care delivery-including unsupervised machine learning to uncover novel VHD phenotypes, generative AI for automated reporting, the use of digital twins to simulate interventions, and the integration of multiple AI agents to support heart team meetings. These advances are followed by the emerging use of AI in robotic transoesophageal and intracardiac echocardiography, as well as in fusion fluoroscopy imaging, to guide valve interventions. While outlining the challenges inherent in this rapidly evolving field, the review's central contribution is its vision to connect the continuum-from AI-enabled community screening to personalized, image-guided therapies at tertiary care centres-offering a scalable and equitable model for VHD care.