Free Hand Research Articles

The impact of robot-assisted spine surgeries on clinical outcomes: A systemic review and meta-analysis.

Medical robotics has enabled a significant advancement in the field of modern spine surgery, especially in pedicle screw fixation. A plethora of studies focused on the accuracy of pedicle fixation in robotic-assisted (RA) technology. However, it is not clear whether RA techniques can improve patients' clinical outcomes. We retrieved relevant studies that compare the differences between RA and freehand (FH) techniques in spine surgeries from the following databases: PubMed, Embase, Cochrane Library and Web of Science. The perioperative outcomes of this technology were measured with parameters including radiation exposure, operative time, the length of hospital stay, complication rates and revision rates. Two reviewers independently reviewed the studies in our sample, assessed their validity and extracted relevant data. Our search resulted in a sample of 23 eligible studies, which involved 1247 patients (5042 pedicle screws) in the RA group and 1273 patients (4830 pedicle screws) in the FH group. With regard to the radiation exposure, the fluoroscopy time was less in surgeries assisted by Mazor robots (standard mean difference [SMD] = -0.96, 95% CI = -1.60 to -0.31) but more in Tianji robots (SMD = 0.91, 95% CI = 0.17 to 1.66) and ROSA robots (SMD = 2.57, 95% CI = 2.01 to 3.13). For radiation dose, a decrease was observed in Tianji robots (SMD = -1.59, 95% CI = -2.13 to -1.05). In the lumbar subgroup, the use of robots increased the operative time (SMD = 0.53, 95% CI = 0.19 to 0.86). In the degenerative diseases (DG) group, there was a significant decrease in the length of hospital stay when robots were introduced (SMD = -0.30, 95% CI = -0.48 to -0.12). While in the DF (deformity) and DG group, a significant increase was found (SMD = 0.17, 95% CI = 0.02 to 0.32). The complication (OR = 0.41, 95% CI = 0.26 to 0.66) and the revision rates (OR = 0.38, 95% CI = 0.24 to 0.60) showed a significant decrease in the RA group compared to the conventional FH group. This study suggests that RA spine surgeries would result in fewer complications, a lower revision rate and shorter length of hospital stay. As the technology continues to evolve, we may expect more applications of robotic systems in spine surgeries.

Accuracy of freehand external ventricular drain placement in patients after a large decompressive hemicraniectomy

Our study aim is to evaluate the accuracy of freehand external ventricular drain (EVD) placement, without the use of adjuncts to placement, immediately following a large decompressive hemicraniectomy (DC). We performed a retrospective cohort analysis comparing patients who underwent freehand EVD placement immediately after a DC, to those who underwent freehand EVD placement without DC. Computed tomography (CT) studies were used to assess accuracy based on catheter tip location. Intracranial catheter length, pre- and post-operative Evan’s Index, and midline shift pre- and post-operatively were analysed as separate variables in each group. A previously described grading system was used to assess the accuracy of free hand EVD placement. There were a total 110 patients overall; DC group, n = 50; non-DC group, n = 60. There was a significant reduction from pre-operative midline shift to post-operative midline shift in the DC group (9.13 vs 6.02 mm; p = 0.0064). There was no significant difference in accuracy between the two groups (p = 0.8917), and similar rates of Grade 1 – i.e. optimal – catheter tip location (DC = 78% vs non-DC = 81%) were found. All analysed variables comparing both Grade 1 subgroups (pre- and postoperative Evan’s Index, and midline shift) showed significant differences between them. Mean catheter length in Grade 1 EVD placement showed a statistically significant difference between the DC and non-DC groups (63.78 vs 59.96 mm, respectively; p = 0.009). An EVD, after DC for traumatic and non-traumatic intracranial pathologies, can be accurately placed by freehand.

Safety and accuracy of robot-assisted placement of pedicle screws compared to conventional free-hand technique: a systematic review and meta-analysis

BACKGROUND CONTEXTThe introduction and integration of robot technology into modern spine surgery provides surgeons with millimeter accuracy for pedicle screw placement. Coupled with computer-based navigation platforms, robot-assisted spine surgery utilizes augmented reality to potentially improve the safety profile of instrumentation. PURPOSEIn this study, the authors seek to determine the safety and efficacy of robotic-assisted pedicle screw placement compared to conventional free-hand (FH) technique. STUDY DESIGN/SETTINGWe conducted a systematic review of the electronic databases using different MeSH terms from 1980 to 2020. OUTCOME MEASURESThe present study measures pedicle screw accuracy, complication rates, proximal-facet joint violation, intraoperative radiation time, radiation dosage, and length of surgery. RESULTSA total of 1,525 patients (7,379 pedicle screws) from 19 studies with 777 patients (51.0% with 3,684 pedicle screws) in the robotic-assisted group were included. Perfect pedicle screw accuracy, as categorized by Gerztbein-Robbin Grade A, was significantly superior with robotic-assisted surgery compared to FH-technique (Odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.20–2.35; p=.003). Similarly, clinically acceptable pedicle screw accuracy (Grade A+B) was significantly higher with robotic-assisted surgery versus FH-technique (OR: 1.54, 95% CI: 1.01–2.37; p=.05). Furthermore, the complication rates and proximal-facet joint violation were 69% (OR: 0.31, 95% CI: 0.20–0.48; p<.00001) and 92% less likely (OR: 0.08, 95% CI: 0.03–0.20; p<.00001) with robotic-assisted surgery versus FH-group. Robotic-assisted pedicle screw implantation significantly reduced intraoperative radiation time (MD: −5.30, 95% CI: −6.83–3.76; p<.00001) and radiation dosage (MD: −3.70, 95% CI: −4.80–2.60; p<.00001) compared to the conventional FH-group. However, the length of surgery was significantly higher with robotic-assisted surgery (MD: 22.70, 95% CI: 6.57–38.83; p=.006) compared to the FH-group. CONCLUSIONThis meta-analysis corroborates the accuracy of robot-assisted pedicle screw placement.

Community pharmacy services and preparedness during COVID-19 outbreak in Madinah, Saudi Arabia

BackgroundWearing facial masks, hand hygiene, and social distancing are highly recommended preventive measures against COVID-19. Masks and disinfectants are usually sold in community pharmacies that are supposed to undertake extreme precautions to avoid cross infection among clients. It is also their responsibility to play a prominent role in educating the community regarding this outbreak. ObjectivesTo investigate the preparedness of private community pharmacies in Madinah, Saudi Arabia, for the COVID-19 outbreak with regard to safety measures, customer education, and quality of preventive aids sold by them. MethodsOne hundred pharmacies were visited by simulated clients. The availability of free hand disinfectants, masks, gloves, and customer educational aids as well as the measures employed to ensure maintenance of safe distances between customers were documented. The adherence of pharmacists and customers to safety precautions and the behavior of pharmacists against violators of regulations were also observed. Finally, the availability and quality of facial masks and hand disinfectants sold by these pharmacies was documented. ResultsFifty-five pharmacies offered free hand disinfectants but only in three of them all customers used them. Only two pharmacies offered free disposable masks and temperature screening was available in only one pharmacy. Educational aids were found in 31 pharmacies and only 53 pharmacies used visual indicators for social distancing. Violation of wearing masks by pharmacy personnel and customers was seen in 34 and 87 pharmacies, respectively. Social distancing was violated in 64 pharmacies and intervention by staff was seen in only three of them. Finally, facial masks were available for sale in only 35 pharmacies, and in 23 of these, the quality was questionable; hand disinfectants were available in 84 pharmacies, and in 14 of these, the quality was unknown. ConclusionsCommunity pharmacies in Madinah were short of registered, high-quality facial masks during the survey. Means to control the transmission of infection inside pharmacies were unsatisfactory. Society has shown poor compliance to preventive measures against COVID-19 infection and the role of community pharmacists in promoting compliance was found to be poor. The study reveals an unsatisfactory level of preparedness of Madinah community pharmacies for the pandemic.

Precision and trueness of implant placement with and without static surgical guides: An in vitro study

Statement of problemMalpositioning of implants is one of the main factors leading to hard- and soft-tissue deficiencies. Whether static computer-guided implant placement increases accuracy and prevents malpositioning is unclear. PurposeThe purpose of this in vitro study was to determine accuracy defined by trueness and precision (according to International Organization for Standardization 5725) of computer-assisted implant surgery (fully guided and partially guided) in comparison with freehand single implant placement. Material and methodsImplants (n=20) were placed fully guided (sleeve-bone distance of 2, 4, or 6 mm), partially guided (guide used for pilot drill), or free hand in identical replicas produced from a cone beam computed tomography (CBCT) scan of a partially edentulous patient. The achieved implant position was digitized by using a laboratory scanner and compared with the planned position. Trueness (planned versus actual position) and precision (difference among implants) were determined. The 3D-offset at the crest of the implant (root mean square between virtual preoperative planning and postoperative standard tessellation language file) was defined as the primary outcome parameter. The means, standard deviation, and 95% confidence intervals were analyzed statistically with 1-way ANOVA and the Scheffé procedure. ResultsFully guided implant surgery achieved significantly lower 3D deviations between the planned and actual implant position with 0.22 ±0.07 mm (2-mm sleeve-bone distance) than partially guided 0.69 ±0.15 mm and freehand placement 0.80 ±0.35 mm at the crest (P<.001). The distance among the implants in each group was again lowest in the fully guided group and highest in the freehand group. ConclusionsThe static computer-assisted implant surgery showed high trueness and precision. The closer the sleeve to the bone, the more accurate and precise the method. Freehand implant placement was less accurate and precise than computer-assisted implant surgery (partially or fully).

200. Comparison of freehand, fluoro-guided, CT navigation, and robot-guided TLIF and ALIF

BACKGROUND CONTEXT Screw placement in transforaminal interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) can be done with open free hand (FH), fluoroscopy-guided (FG), spinal navigation (NAV), or robotic guided (RG) techniques. Varied techniques may affect perioperative (periop) outcomes. Few studies compare all four guidance techniques. PURPOSE Compare the perioperative outcomes between FH, FG, NAV, and RG TLIF and ALIF. STUDY DESIGN/SETTING Single center retrospective cohort study PATIENT SAMPLE A total of 1,646 patients who underwent 1-2 level TLIF or 1-3 level ALIF from 2012-2019. OUTCOME MEASURES Outcomes: registration failure, operative time (OT), radiation dosage (RD), estimated blood loss (EBL), length of stay (LOS), and periop complications, and retursn to OR up to 90 days. METHODS Patients undergoing 1-2 level TLIF or 1-3 level ALIF were included. Analysis of variance (ANOVA) and χ2test were used to analyze differences in outcomes with significance set at p RESULTS A total of 1,202 1-2 level TLIFs were included (843 FH, 175 FG, 40 NAV, 144 RG) TLIFS. 444 1-3 level ALIFs were included: 337 FH, 25 FG, and 80 RG ALIFs. Demographics were similar amongst ALIF cohorts except significantly more FH-ALIF smokers and TLIF cohorts after propensity matching for levels fused. Amongst the TLIF Cohorts: OT and LOS longest in NAV (291.67±89.85 min; p CONCLUSIONS NAV-TLIF had significantly differences in EBL, RD, periop complications, and return to OR 30 days. PSM for levels fused show postop complications rate remain significant with other factors and radiographic dosage remaining significant. RG TLIF and RG ALIF had the worst perioperative complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Accuracy of C-Arm Guided Insertion of Ommaya Reservoir Tube in Recurrent Cystic Craniopharyngiomas

Abstract Background: Caniopharyngiomas in spite of being benign tumors they have a high rate of recurrence of which cysts constitute major component. Ommaya Reservoir System (ORS) is a simple manoeuvre for percutaneous drainage of cysts. Aim of Study: To evaluate the efficacy of using C-arm as a guiding tool for placement of Ommaya reservoir tube in predominantly cystic recurrent craniopharyngiomas. Patients and Methods: This study included 8 patients with clinically symptomatic and radiologically confirmed recurrent craniopharyngioma with significant cystic part. These patients were treated by C-arm guided insertion of Ommaya reservoir tube. The technique is described in details. CT brain was obtained in the first post-operative night to assess the position of the tube. Post-operative clinical and radiological evaluations were compared to the pre-operative. Results: This study included 6 males and 2 females, ranging in age from 5 years to 38 years with mean age of 18.4 years. Headache was the most common presenting complaint, followed by visual impairment. All surgeries were performed with C-arm guidance and post-operative CT brain documented satisfactory position of the tube in 7 cases and only one case required second look surgery for repositioning of the tube with the same technique. Significant post-operative improve-ment of headache and visual symptoms were encountered in all cases due to decompression of the optic chiasm by cyst drainage. Conclusion: C-arm assisted insertion of Ommaya reservoir tube is a reliable method that can minimize the errors of free hand technique and of special value in low facility centers.

Accuracy study of a binocular-stereo-vision-based navigation robot for minimally invasive interventional procedures.

BACKGROUNDMedical robot is a promising surgical tool, but no specific one has been designed for interventional treatment of chronic pain. We developed a computed tomography-image based navigation robot using a new registration method with binocular vision. This kind of robot is appropriate for minimal invasive interventional procedures and easy to operate. The feasibility, accuracy and stability of this new robot need to be tested.AIMTo assess quantitatively the feasibility, accuracy and stability of the binocular-stereo-vision-based navigation robot for minimally invasive interventional procedures.METHODSA box model was designed for assessing the accuracy for targets at different distances. Nine (three sets) lead spheres were embedded in the model as puncture goals. The entry-to-target distances were set 50 mm (short-distance), 100 mm (medium-distance) and 150 mm (long-distance). Puncture procedure was repeated three times for each goal. The Euclidian error of each puncture was calculated and statistically analyzed. Three head phantoms were used to explore the clinical feasibility and stability. Three independent operators conducted foramen ovale placement on head phantoms (both sides) by freehand or under the guidance of robot (18 punctures with each method). The operation time, adjustment time and one-time success rate were recorded, and the two guidance methods were compared.RESULTSOn the box model, the mean puncture errors of navigation robot were 1.7 ± 0.9 mm for the short-distance target, 2.4 ± 1.0 mm for the moderate target and 4.4 ± 1.4 mm for the long-distance target. On the head phantom, no obvious differences in operation time and adjustment time were found among the three performers (P > 0.05). The median adjustment time was significantly less under the guidance of the robot than under free hand. The one-time success rate was significantly higher with the robot (P < 0.05). There was no obvious difference in operation time between the two methods (P > 0.05).CONCLUSIONIn the laboratory environment, accuracy of binocular-stereo-vision-based navigation robot is acceptable for target at 100 mm depth or less. Compared with freehand, foramen ovale placement accuracy can be improved with robot guidance.

Comparison of the Accuracy and Safety of Pedicle Screw Placement in Thoracic Spine Between 3D Printed Navigation Templates and Free Hand Technique

Relevance. Transpedicular spine fixation is considered the gold standard for posterior stabilization of the spine in various pathological processes. The most common implantation technique is the free hand method. But today the implantation with 3D printed individual navigation templates is gaining popularity. Purpose — to compare results of the pedicle screw placement in thoracic spine with application of 3D printed navigation templates by various design and free hand technique. Materials and Methods. Results of the three group of patients were analyzed based on postoperative CT. In group 1 (free hand) 112 screws were placed to 23 patients. In group 42 screws were placed to 11 patients using bilateral monosegmental navigation templates, in group 3 (13 patients, 42 screws) — using bilateral monosegmental templates with additional support on the spinous process. The safety of implantation was assessed and compared in all groups. In groups 2 and 3 the accuracy was also evaluated based on the difference between the planned and actual screws trajectory. Results. In group 1 safety grade 0 was registered in 66,96%, safety grade 1 in 18,75%, safety grade 2 — in 9,82%, safety grade 3 — in 4,46%. In group 2 grade 0 was registered in 85,71%, safety grade 1 — in 14,29%. In group 3 grade 0 — in 90,74%, safety grade 1 — in 9,26%. There were no cases of the cortical bone perforation for more than the half of the screw diameter in groups 2 and 3. The differences in the safety parameters are significant between free hand and both groups with application of the navigation templates. Assessment of the deviation hasn’t revealed significant difference depending on the type of the templates. Conclusion. The use of the individual navigation templates for pedicular screws implantation in the thoracic spine is safer than the free hand method (p0.05). Single-level bilateral matrices made by FDM technology from polylactide with support on a part of the dorsal vertebral structures make it possible to achieve the high implantation accuracy. Additional support on the spinous process does not lead to a statistically significant improvement in accuracy and safety indicators (p0.05), while requiring extended dissection and resection of the ligamentous elements.

Effect of stress on the leaf anatomy of sugarcane cultivars with different drought tolerance (Saccharum officinarum, Poaceae)

ABSTRACT. Introduction: Drought is an important stress factor for sugarcane production in many areas of the world. Water proportion and moisture indices are applicable information for agronomic planning to forecast water excess or deficit during the crop cycle. Objective: Leaf anatomical features of two different sugarcane Saccharum ‘UT12’ (drought susceptible cultivar) and Saccharum ‘UT13’ (drought tolerant cultivar) were compared under early drought stress situation between 30 and 90 days after planting. Methods: Forty leaf anatomical features were investigated using peeling and free hand sectioning technique. Results: Some anatomical characteristics showed response to drought stress. Saccharum ‘UT12’ demonstrated higher sensitivity toward anatomical characteristics than Saccharum ‘UT13’. A total of 23 and 15 out of the 40 anatomical characteristics showed significance in Saccharum ‘UT12’ and Saccharum ‘UT13’, respectively. Some anatomical features such as cell wall and cuticle thickness, vascular bundle size, stomatal size and density can be used as important markers for drought stress assessment in sugarcane leaf. Conclusions: This is the first report describing comparative leaf anatomy of sugarcane Saccharum ‘UT12’ and Saccharum ‘UT13’ in Thailand under drought stress. Results will provide important information to improve adaptation mechanisms of tolerant sugarcane cultivars under initial drought stress situations.

Pedicle Screw Insertion: Is O-Arm–Based Navigation Superior to the Conventional Freehand Technique? A Systematic Review and Meta-Analysis

Although O-arm-based navigation (ON) has been considered a better choice than the conventional freehand (FH) technique for spine surgery, clinical evidence showing the accuracy of ON compared with the FH technique is limited. The purpose of this study was to evaluate the accuracy of pedicle screw insertion under ON compared with the FH technique. The Cochrane Library, Ovid, Web of Science, PubMed, Embase, and CNKI online databases were searched up to January 2020. Because only a few randomized controlled trials were anticipated, prospective and retrospective comparative studies were also evaluated to compare the accuracy of pedicle screw insertion between ON and FH. Statistical analysis was performed using Stata 16.0. The primary outcomes extracted from articles that met the selection criteria were expressed as odds ratios for dichotomous outcomes with a 95% confidence interval. A χ2 test and I2 statistics were used to evaluate heterogeneity. A total of 20 reviews were included in this meta-analysis without identifying additional studies from the references of published articles. These reviews included 1422 patients and 9982 screws. ON was used to insert 4797 pedicle screws and 5185 pedicle screws were inserted using the conventional FH technique with C-arm assistance. The meta-analysis showed that ON is significantly more accurate than FH pedicle screw insertion (odds ratio, 2.46; 95% confidence interval, 1.92-3.16; I2= 43.4%; P= 0.021). I2 indicates that the studies have a moderate statistical heterogeneity; subgroup analysis decreased heterogeneity significantly. Compared with conventional methods, navigation provides greater accuracy in the placement of pedicle screws, accelerates the insertion, and reduces the complications associated with screw insertion. However, it may increase exposure time to radiation, which may harm the patient's or surgeon's health.

Nutritional Status in Patients with Esophageal Cancer Receiving Chemoradiation and Assessing the Efficacy of Usual Care for Nutritional Managements.

Background:Malnutrition is prevalent in esophageal cancer patients which affects cancer prognosis. The purpose of this study was a comprehensive assessment of nutritional status during Chemoradiation (CRT). Methods:Newly diagnosed adults with esophageal cancer were recruited for this study. Patient-Generated- Subjective Global Assessment (PG-SGA), anthropometric indices, body composition, dietary intake, laboratory tests, and nutritional-related complications were assessed before, after, and 4 to 6 weeks after CRT. Results:Seventy-one cases were enrolled. The mean age was 66.8±12 years. Patients’ mean weight loss was 2.42±2.4 kilograms during treatment. A significant reduction observed in mean MUAC (26.68±4.9 vs. 25.42±5.1 cm), fat mass percentage (24.11±11.8 vs. 22.8±12.5), fat free mass index (16.87±2.4 vs. 16.47±2.6 kg/m2) and hand grip strength (43.2±19 vs. 36.1±20 kg) during CRT (all p-values <0.0001). We had also a non-significant change in mean energy intake (19.5±11 vs. 18.3±11 kcal/kgw. day) and protein intake (0.56±0.4 vs. 0.66±0.5 g/kgw.day) during CRT. In our assessment before, immediately after and 4-6 weeks following CRT, we recorded energy intake insufficiency in 55.7%, 58.7% and 27.3% and protein intake inadequacy in 89.8%, 89.1% and 72.7% of cases, respectively. The most common complications were dysphagia (56.7%), anorexia (25%), and constipation (47.9%) at admission. Dysphagia improved in some cases (42%), but anorexia (35%), early satiety (25%), Esophagitis (25%), dysosmia (21%) and dysgeusia (17%) were increased as CRT complication. yet, 25% of patients had dysphagia and 34.4% had constipation 4-6 weeks after CRT. The twelve-months mortality was significantly associated with lower BMI after CRT, primary PG-SGA score, weight loss, BMI<18.5, MUAC, physical performance, living in rural or urban areas, addiction. Conclusion:Our study demonstrated a high prevalence of malnutrition among esophageal cancer patients which worsened during Chemoradiotherapy. Our findings warrant early screening and monitoring of nutritional status and effective nutritional interventions with symptoms management during treatment in these patients.

Thermal imaging of the fetus: An empirical feasibility study.

Digital Infrared Thermal Imaging (DITI) has much potential in the field of maternal-fetal health and wellbeing research. The fact that it is totally non-invasive is particularly important in this context. The purpose of this study was, for the first time, to assess DITI’s ability to record fetal presentation and position, and other pregnancy-related physiological factors, via their superficial thermal prints. Ten healthy pregnant women (approximately 34–37 weeks of gestation) were recorded with two thermal imaging cameras (Flir C3 and i3 TE-Q1) from five different viewpoints. Participants’ views about the use of DITI in research and clinical practice were also assessed by a completion of a survey. Free hand polygon region of interests (ROIs) were drawn in order to include the entire anatomical area for investigation. The use of free hand polygon ROIs showed high reliability. Thermal images analysis revealed that fetuses presenting cephalically can be identified by the use of DITI, under specific conditions. Fetal movements influenced the thermal patterns that were produced. Future studies need to verify the heat patterns on the skin related to the placenta location, in order to understand the produced thermal recordings. Pregnant women rated the idea of using DITI in research and clinical practice very highly. This work represents a first contribution towards the use of DITI for the recording of fetal presentation and position. As it does not require direct contact and since it is completely non-invasive, it could be used to record maternal-fetal dynamic dyadic interaction in pregnancy. However, although the preliminary results are promising, further trans-disciplinary studies with a well-established protocol, more sophisticated thermal cameras, and bigger cohorts are needed.

Hand-adaptive user interface: improved gestural interaction in virtual reality

Most interactive user interfaces (UIs) for virtual reality (VR) applications are based on the traditional eye-centred UI design principle, which primarily considers the user’s visual searching efficiency and comfort, but the hand operation performance and ergonomics are relatively less considered. As a result, the hand interaction in VR is often criticized as being less efficient and precise. In this paper, the user’s arm movement features, such as the choice of the hand being used and hand interaction position, are hypothesized to influence the interaction results derived from a VR study. To verify this, we conducted a free hand target selection experiment with 24 participants. The results showed that (a) the hand choice had a significant effect on the target selection results: for a left hand interaction, the targets located in spaces to the left were selected more efficiently and accurately than those in spaces to the right; however, in a right hand interaction, the result was reversed, and (b) the free hand interactions at lower positions were more efficient and accurate than those at higher positions. Based on the above findings, this paper proposes a hand-adaptive UI technique to improve free hand interaction performance in VR. A comprehensive comparison between the hand-adaptive UI and traditional eye-centred UI was also conducted. It was shown that the hand-adaptive UI resulted in a higher interaction efficiency and a lower physical exertion and perceived task difficulty than the traditional UI.

Robot-assisted orthopedic surgery in the treatment of adult degenerative scoliosis: a preliminary clinical report

Study designA single-institution, retrospective cohort study.ObjectiveTo compare the accuracy and short-term clinical outcomes of pedicle screw placement between robot-assisted (RA) and freehand (FH) technique in the treatment of adult degenerative scoliosis (ADS).MethodsFrom February 2018 to October 2019, 97 adult patients with degenerative scoliosis admitted to our department were retrospectively reviewed. Thirty-one patients received robot-assisted pedicle screw placement (RA group), and 66 patients underwent freehand pedicle screw placement (FH group). Patient demographics and short-term clinical outcomes were recorded and compared between two groups. Gertzbein-Robbins grading system was adopted to evaluate the accuracy of pedicle screw placement by means of postoperative CT scan. Short-term clinical outcomes consist of operative time, intraoperative blood loss, length of hospital stay (LOS), radiological parameters, Scoliosis Research Society-22 (SRS-22) scores before the operation, 6 months after operation, adverse events, and revisions.ResultsThe accuracy of screw placement was higher than that of the FH group (clinically acceptable 98.7% vs. 92.2%; P< 0.001). Intraoperative blood loss of the RA group was less than those in the FH group (499 vs. 573 ml; P < 0.001). Operative time (283.1 vs. 291.9 min; P = 0.31) and length of stay (12.8 vs. 13.7 days; P = 0.36) were compared between RA and FH groups. In terms of radiological parameters, both of groups were improved postoperatively. The SRS-22 scores at 6 months after operation from both groups were better than those before operation. For surgery-related complication, one case had pressure sores in the RA group while two cases developed dural tears in the FH group. No revision was required in both groups.ConclusionCombined with other surgical correction modalities, robot-assisted pedicle screw fixation is an effective and safe method of treating degenerative scoliosis. Due to its satisfactory surgical outcomes such as higher accuracy and less trauma, it provides a good alternative for clinical practice.Level of evidence3.

Accuracy and Efficiency of a Dynamic Navigation System for Locating Calcified Canals

IntroductionCalcified canals present a challenge during endodontic treatments. The purpose of this study was to compare the accuracy and efficiency of a dynamic navigation system (DNS) to the freehand (FH) method for locating calcified canals in human teeth. MethodsSixty human single-rooted teeth with canal obliteration were selected and mounted in dry cadaver jaws. Based on cone-beam computed tomographic scans of the jaws, the drilling path and depth were virtually planned to use X-Guide software (X-Nav Technologies, LLC, Lansdale, PA). Access preparation was made with navigation in the DNS group and without guidance in the FH group by 2 operators with different levels of experience. Postoperative cone-beam computed tomographic scans were taken of all teeth. Linear and angular deviations and reduced dentin thickness at 2 levels were measured. The time for locating the canal, the number of mishaps, and the unsuccessful attempts were determined and analyzed. ResultsThe mean linear and angular deviations, reduced dentin thickness (at both levels), the time for access cavity preparation, and the number of mishaps in the DNS group were significantly less than the FH group (P ≤ .05). The unsuccessful attempts were not different between the 2 groups (P > .05). The time for access preparation was significantly shorter for the board-certified endodontist in the FH group (P ≤ .05). ConclusionsThe DNS was more accurate and more efficient than the FH technique in locating calcified canals in human teeth. This novel DNS can help clinicians avoid catastrophic mishaps during access preparation in calcified teeth.

Accuracy Assessment of Freehand Pedicular Screw Placement.

The purpose of this prospective study was to determine the accuracy of pedicular screw insertion without the use of fluoroscopy. This study was conducted on patients with spinal diseases in need of pedicular screw fixation and fusion. The included patients suffered from such conditions as vertebral fracture, spinal stenosis, kyphosis, tumor, and pelvic fractures and were managed with triangular osteosynthesis fixation. However, those with scoliosis deformity were excluded from the study. A total of 760 pedicular screws were inserted in C7 to S1 vertebrae without using fluoroscopy. The locations of the screws were assessed by means of computed tomography scan after the surgery. The data were analyzed in SPSS software (version 22) using the Chi-square test. Out of 387 thoracic screws and 373 lumbar screws, 65 (16.8%) and 34 (9.1%) screws perforated the pedicle wall or vertebral body, respectively. The most frequent locations of perforation in the thoracic and lumbar spine were the anterior cortex of the vertebral body and medial wall of the pedicle, respectively. Except for the perforation of the anterior vertebral body (P=0.0001), there was no difference between the left and right sides or between thoracic and lumbar sites in terms of the preformation of the screw. No complication was observed due to screw perforation. Our findings revealed the unnecessity of using fluoroscopy in spine surgeries for the insertion of pediculate screws. In this regard, the use of fluoroscopy for the placement of pedicular screw resulted in similar accuracy and complications, as compared to the free hand procedure.

Authoritarian power in space, time and exile

Autocrats have been shown to exert influence over their populations and dissidents abroad through strategies such as ‘transnational repression’ or ‘diaspora engagement’ policies, demonstrating that authoritarian power carries across borders. But existing work on extra-territorial authoritarian power has tended to view state power as a stand-alone variable that endows regimes with a relatively free hand to make their own diaspora policies. This is despite that studies of authoritarianism inside states, including those observing the ‘dynamics of contention,’ have consistently highlighted the relational and contingent nature of authoritarian power. This paper asks whether the iterative dynamics of contention that describe regime-opposition relations within state boundaries endure between authoritarian regimes and their exiles? It brings together the literatures on extra-territorial authoritarian power and the topology of power with that on contentious politics in authoritarian regimes to undertake a case study on the relationship between the Syrian government and the exiled Syrian Muslim Brotherhood. It finds that extra-territorial authoritarian is relational and contingent on the political context and its recipients, and shares many of the characteristics of authoritarian power inside state boundaries.

Utilization of a Stress Ball to Diminish Anxiety During Nail Surgery

Anxiety is commonly encountered by patients undergoing nail surgery. Squeezing a stress ball with the free hand does not interfere with the surgical procedure, and it is a widely accessible and cost-effective technique that reduces anxiety in patients undergoing nail surgery.

A comparison of free-hand method and electromagnetic navigation technique for the distal locking during intramedullary nailing procedures: a meta-analysis.

Some studies have reported that the electromagnetic navigation (EN) technique is better than the free-hand (FH) method. Nevertheless, there are few clinical trials. In recent years, several clinical trials have been conducted, providing sufficient information to compare the two methods. We compared the FH and EN techniques (SURESHOT, Smith and Nephew, Inc., Memphis, TN) in terms of the distal locking time, exposure time, first success rate, healing time and operative time. We comprehensively searched the Medline, Embase, and Cochrane library databases according to predetermined inclusion and exclusion criteria, and then we extracted data for specific variables from these reports. The risk of bias was assessed. Stata 13.0 was used for analysis. Nine studies involving 579 patients were pooled in this study. The meta-analysis showed that EN was associated with a shorter distal locking time (P = 0.001) and exposure time (P = 0.001) than FH performed by surgeons who are not proficient in using the FH technique. No significant differences were found in the first success rate (P = 0.231), healing time (P = 0.09) or operative time (P = 0.510). The EN technique has the advantages of a shorter distal locking time and smaller amount of ionizing radiation exposure compared with the FH technique.