Intraoperative Fluoroscopic Images Research Articles

Impact of operative position on rotational alignment after intramedullary nailing of trochanteric fractures: a comparative analysis of lateral decubitus versus supine position.

Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures. The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant,andexcessive.The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared. The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time. Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time.

Effects of Parallax and Distortion in Total Ankle Arthroplasty.

Surgeons rely on intraoperative fluoroscopy to assist in placement of implant components during total ankle arthroplasty (TAA). Parallax alters the direction of an object when viewed from two different points, resulting in image distortion. The purpose of this study was to evaluate parallax/distortion in intraoperative fluoroscopic images during TAA. A retrospective review of all TAAs performed by two surgeons (R.W.M. and B.S.) from August 2019 to April 2023 were reviewed. Intraoperative fluoroscopic anteroposterior (AP) ankle views were evaluated for any obvious parallax image distortion. Cases with obvious parallax distortion were included for angular evaluation of AP intraoperative fluoroscopic and first postoperative plain films. The tibia was marked at 2-centimeter intervals to create zones from the proximal stem of the implant. The anatomical axis of the tibia (AAT) was drawn at the mid-diaphysis. The anatomic lateral distal tibial angle (aLDTA) and anatomic axis deviation (AAD) were measured for each zone. A total of 22 TAAs were performed during the study period. Four cases were excluded due to inadequate imaging, leaving a total of 18 TAAs for review. We found 6 of 18 (33.3%) cases had obvious parallax distortion. We found the average aLDTA was 90.9° (84°-101°). At the most proximal tibial zone, the average aLDTA was 94° (91°-101°). We found the average AAD was 4.7 (0.5-17.2) mm. The AAD ranged from 0.5 to 17.2 mm lateral to 0.8 to 8.2 mm medial. Postoperative plain film radiographs displayed a normal aLDTA and an AAT centered within the ankle joint. Parallax can distort the appearance of the tibia on fluoroscopic images. Deviation from the normal aLDTA and anatomical axis should be anticipated. Surgeons should be aware of the potential impact of parallax and ways to mitigate these effects.

Validation of the Lift-Off Screw Technique in Patients Undergoing Corrective Osteotomy for Malunited Distal Radius Fractures

The purpose of this study was to validate the clinical accuracy of the lift-off screw (LOS) technique for volar tilt correction (VTC) in patients undergoing corrective osteotomy for dorsally angulated distal radius fracture malunions. We conducted a retrospective review of 23 patients with dorsally angulated distal radius fracture malunions treated with corrective osteotomy using the LOS technique. The LOS equation Ls= [tan(Tc) ∗ Lp+ C]/[cos(⍬s)] and standardized intraoperative fluoroscopic images were used to determine and compare the calculated and clinical VTC and final volar tilt. Correlations between the LOS length and the clinical VTC were calculated, as well as between the desired VTC and the correction accuracy. Preoperative volar tilt ranged from-6° to-50° (mean=-22.9° ± 10.6°). The calculated VTC was 32.7° ± 9.4°, and the clinical VTC achieved was 25.8° ± 9.3°. The difference between the clinical and calculated correction was-6.9°, with an average postoperative clinical volar tilt of 2.8° ± 5.7°, compared with a calculated volar tilt of 9.7° ± 4.4°. There was a moderately strong positive correlation between LOS screw length and clinical VTC achieved, and a moderately weak negative correlation between the desired amount of correction and the accuracy of the correction. The LOS technique is a reproducible method to plan the amount of sagittal plane correction during corrective osteotomy surgery for dorsally angulated distal radius fracture malunions. We demonstrate that this technique underestimates the clinical correction achieved by an average of 7°, with larger deformities experiencing greater undercorrection. Undercorrection of volar tilt during corrective osteotomy should be anticipated by surgeons and considered in future implant and cutting guide designs. Therapeutic IV.

Intraoperative fluoroscopy skills in distal radius fracture surgery: valid and reliable assessment on a novel immersive virtual reality simulator.

Orthopedic trainees must be able to perform intraoperative fluoroscopy imaging to assess the surgical result after volar locking plate surgeries of distal radius fractures. Guided by Messick's contemporary validity framework, the aim of our study was to gather evidence of validity for a test of proficiency for intraoperative imaging of a distal radius fracture using a novel immersive virtual reality simulator. 11 novices and 9 experienced surgeons employed at orthopedic departments completed 2 individual simulator sessions. At each session the participants performed 3 repetitions of an intraoperative fluoroscopic control of a distal radius fracture, consisting of 5 different fluoroscopic views. Several performance metrics were automatically recorded by the simulator and compared between the 2 groups. Simulator metrics for 3 of the 5 fluoroscopic views could discriminate between novices and experienced surgeons. An estimated composite score based on these 3 views showed good test-retest reliability, ICC = 0.82 (confidence interval 0.65-0.92; P < 0.001). A discriminatory standard was set at a composite score of 6.15 points resulting in 1 false positive (i.e., novice scoring better than the standard), and 1 false negative (i.e., experienced surgeon scoring worse than the standard). This study provided validity evidence from all 5 sources of Messick's contemporary validity framework (content, response process, internal structure, relationship with other variables, and consequences) for a simulation-based test of proficiency in intraoperative fluoroscopic control of a distal radius fracture fixated by a volar locking plate.

Domain adaptation strategies for 3D reconstruction of the lumbar spine using real fluoroscopy data

In this study, we address critical barriers hindering the widespread adoption of surgical navigation in orthopedic surgeries due to limitations such as time constraints, cost implications, radiation concerns, and integration within the surgical workflow. Recently, our work X23D showed an approach for generating 3D anatomical models of the spine from only a few intraoperative fluoroscopic images. This approach negates the need for conventional registration-based surgical navigation by creating a direct intraoperative 3D reconstruction of the anatomy. Despite these strides, the practical application of X23D has been limited by a significant domain gap between synthetic training data and real intraoperative images.In response, we devised a novel data collection protocol to assemble a paired dataset consisting of synthetic and real fluoroscopic images captured from identical perspectives. Leveraging this unique dataset, we refined our deep learning model through transfer learning, effectively bridging the domain gap between synthetic and real X-ray data. We introduce an innovative approach combining style transfer with the curated paired dataset. This method transforms real X-ray images into the synthetic domain, enabling the in-silico-trained X23D model to achieve high accuracy in real-world settings.Our results demonstrated that the refined model can rapidly generate accurate 3D reconstructions of the entire lumbar spine from as few as three intraoperative fluoroscopic shots. The enhanced model reached a sufficient accuracy, achieving an 84% F1 score, equating to the benchmark set solely by synthetic data in previous research. Moreover, with an impressive computational time of just 81.1 ms, our approach offers real-time capabilities, vital for successful integration into active surgical procedures.By investigating optimal imaging setups and view angle dependencies, we have further validated the practicality and reliability of our system in a clinical environment. Our research represents a promising advancement in intraoperative 3D reconstruction. This innovation has the potential to enhance intraoperative surgical planning, navigation, and surgical robotics.

Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring?

Surgical intervention for lateral compression (LC) 1 and 2 pelvic ring fractures is controversial. Posterior ring stabilization remains the most common mode of initial fixation. However, greater mechanical instability is observed in the anterior component of LC pelvic fractures. This study tested whether reduction and percutaneous superior ramus fixation will decrease the instability of LC pelvic fractures on intraoperative fluoroscopic imaging. All adult patients (≥ 18 years) presenting with either a Young-Burgess LC1 or LC2 pelvic ring disruption treated operatively with percutaneous anterior followed by posterior fixation by a single surgeon from July 2021 to June 2023 were retrospectively reviewed. Displacement of the anterior ring to intraoperative manual internal rotation stress examination under fluoroscopy was compared before and after anterior pelvic ring reduction and fixation and prior to posterior pelvic ring fixation. Pre- and post-operative visual analog scores (VAS) for pain were also compared. Twenty-one patients with a mean age of 48.7 years were included. Fifteen patients (71.4%) presented with an LC1, and six (28.6%) with an LC2 injury patterns. Anterior pelvic fixation alone provided 7.5mm reduction in mean displacement of the anterior pelvic ring (pre-operative = 9.2 mm vs. post-operative = 1.6 mm, p < 0.001). VAS significantly decreased from 7.2 one-day pre-operatively to 2.2 twenty-four h post-operatively (p < 0.001). Reduction and fixation of the anterior pelvic ring prior to posterior fixation for LC1 and LC2 pelvic ring disruptions substantially improves mechanical stability on intraoperative stress examination. Combination of percutaneous anterior and posterior fixation significantly decreased VAS above the MCID 24 h after stabilization.

Virtual surgical planning and use of a 3D-printed, patient-specific reduction system for minimally invasive plate osteosynthesis of diaphyseal tibial fractures in dogs: A historic case control study.

To compare the efficacy and clinical outcomes of computed tomography (CT)-based virtual surgical planning (VSP) and a three-dimensional (3D)-printed, patient-specific reduction system to conventional indirect reduction techniques for diaphyseal tibial fractures stabilized using minimally invasive plate osteosynthesis (MIPO) in dogs. A prospective clinical study with a historic control cohort. Dogs undergoing MIPO stabilization of diaphyseal tibial fractures using a custom 3D-printed reduction system (3D-MIPO; n = 15) or conventional indirect reduction techniques (c-MIPO; n = 14). Dogs were prospectively enrolled to the 3D-MIPO group and CT scans were used to design and fabricate a custom 3D-printed reduction system to facilitate MIPO. Medical records were searched to identify dogs for the c-MIPO group. Pre-, intra- and postoperative parameters were compared between groups. The duration from presentation until surgery was 23 h longer in the 3D-MIPO group (p = .002). Fewer intraoperative fluoroscopic images were acquired (p < .001) and mean surgical duration was 34 min shorter in the 3D-MIPO group (p = .014). Median postoperative tibial length, frontal alignment, and sagittal alignment were within 4 mm, 3° and 3°, respectively, of the contralateral tibia in both groups and did not differ between reduction groups (p > .1). Postoperative complications occurred in 27% and 14% of fractures in the 3D-MIPO and c-MIPO groups, respectively. Both reduction methods yielded comparable results. Although the preoperative planning and guide preparation was time consuming, surgery times were shorter and fluoroscopy use was lessin the 3D-MIPO group. VSP and the custom 3D-printed reduction system facilitated efficient MIPO.

Single versus double percutaneous pinning of pediatric distal radius fractures.

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

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

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

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

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

Impact Of Introducing 3D Printing-Assisted Surgery Into Clinical Practice For Traumatic Pelvic And Acetabular Fractures

BackgroundGiven the novelty of three-dimensional (3D) printing-assisted fracture surgery in orthopaedics, surgeon familiarity is limited and learning curve is high. As such, it is unclear how the introduction of 3D printing into clinical practice for pelvic and acetabular fracture surgery would impact perioperative outcomes. The aim of this study was to determine the impact of introducing 3D printing-assisted surgery on perioperative outcomes for traumatic pelvic and acetabular fractures. MethodsWe retrospectively identified consecutive patients who underwent surgical fixation of traumatic pelvic and acetabular fractures from 2018 to 2022 at a single tertiary hospital. The patients included in the study were divided into two groups: (1) 3D printing-assisted surgery and (2) conventional surgery. Baseline demographics and perioperative outcomes of total surgical duration, estimated blood loss, blood transfusion, number fluoroscopy images, fluoroscopy duration and postoperative disposition were recorded and compared between the two groups. ResultsIn total, 26 patients were included in the present study, with 3D printing-assisted surgery being used in 34.6% (n=9) of cases. There were no significant differences in baseline demographics or fracture type between the 3D printing group and conventional group. As compared to patients who underwent conventional surgery, those that underwent 3D printing-assisted surgery had, on average, shorter surgical duration (299.8±88.2 vs 309.1±143.1 mins), lesser estimated blood loss (706.3±330.0 vs 800.0±584.2 ml), lower transfusion rates (50.0% vs 52.9%), lower number of intraoperative fluoroscopy images (62.8±74.5 vs 71.6±47.9 images) and shorter fluoroscopy duration (235.0±79.2 vs 242.3±83.5 mins), although statistical significance was not achieved. None of the patients in the present study developed surgical complications postoperatively. ConclusionThe introduction of 3D printing-assisted surgery in clinical practice for pelvic and acetabular fractures is a safe and viable adjunct in pelvic and acetabular surgery, achieving comparable perioperative outcomes in the initial phase.

Manual Reduction for Subacute Osteoporotic Burst and Severe Compression Thoracolumbar Fractures

The objective of this study was to retrospectively assess the impact of manual reduction (MR) on patients with subacute osteoporotic thoracolumbar burst fractures and severe compression fractures (OTLBFSCFs). From January 2016 to May 2020, 101 cases of OTLBFSCFs were reviewed, comprising 73 women and 28 men, with an average age of 77.4 ± 8.5 years. Preoperative radiographs, CT or MRI scans, intraoperative C-arm fluoroscopic images, and postoperative X-ray films were utilized to evaluate spinal radiographic parameters. Initially, all patients underwent 3 min of prone positioning as posture reduction (PR), followed by 1–3 sessions of six-member MR to approximate anatomical reduction of the fracture. The average preoperative anterior body height ratio (ABH%) and lateral Cobb angle (LCA) were 38.8% ± 6.2% and 22.6° ± 4.2°, respectively. Post-PR, the average ABH% and LCA were 50.5% ± 8.0% and 14.7° ± 2.7°, respectively. Following MR, the average ABH% and LCA were 99.6% ± 2.4% and 0.4° ± 2.4°, respectively. PR achieved an ABH% correction of 11.7%, while MR achieved 49.1%. LCA restoration was 7.9° with PR and 14.3° with MR. It was deduced that MR proved to be safe and efficacious for subacute OTLBFSCFs and could potentially alter the approach to subsequent surgeries.

Functional Acetabular Component Positioning During Direct Anterior Approach Hip Arthroplasty Using a Novel Three-Dimensional Virtual Mesh Imaging System With Fluoroscopy

BackgroundOptimal position of total hip arthroplasty (THA) components is critical for joint mechanics and stability. Acetabular component positioning during supine surgery in direct anterior approach (DAA) THA may be different in the standing position postoperatively, which traditional fluoroscopy is unable to predict. A novel 3-dimensional (3D) image analysis technology (IAT) that uses artificial intelligence to measure the tilt and rotation of the pelvis has enabled prediction of component positioning from supine to standing. The purpose of this study was to compare intraoperative fluoroscopy, non–3D-IAT, and 3D-IAT with postoperative standing radiographs to assess the accuracy of component positioning. MethodsFrom 2022 to 2023, 30 consecutive patients (86.6% women, mean age 59 [range, 55 to 67]) undergoing primary DAA THA with the use of the 3D-IAT were identified. A separate cohort of 148 patients from 2020 to 2021 (85% women, mean age 65 [range, 55 to 69]) who underwent DAA THA with non–3D-IAT was used for comparison. Leg length discrepancy (LLD), cup anteversion, and inclination were manually measured on intraoperative fluoroscopic images and digitally measured using IAT. Follow-up evaluation occurred at 1 month with standing pelvis radiographs measured using Ein Bild Röntgen Analyze–Cup software. Measurements were compared via Wilcoxon signed rank tests where P ≤ .05 indicates significantly different measurements. ResultsMedian LLD, inclination, and anteversion measurements via non–3D-IAT and fluoroscopy were significantly different compared to postoperative standing radiographs (P < .001). The 3D-IAT more accurately predicted LLD, abduction, and anteversion, with values not significantly different from postoperative standing measurements (P = .23, P = .93, and P = .36, respectively). ConclusionsThe use of the 3D-IAT during DAA THA allowed for the more accurate prediction of acetabular component position in the standing position postoperatively.

Accuracy of intraoperative approximation of pelvic tilt using preoperative standing radiographs

BackgroundAnterior approach surgeons who utilize intraoperative fluoroscopy often try to match a preoperative radiograph as a reference for intraoperative cup position. Every degree of inaccuracy in tilt leads to a roughly 0.7° change in anteversion. This study aimed to determine how closely pelvic tilt (PT) is approximated intraoperatively when compared to preoperative anteroposterior (AP) radiographs. MethodsThis was a retrospective review of 193 primary THA's done by 2 surgeons at an academic tertiary referral center between September 2021–January 2023. There were 24 patients excluded for distorted anatomy, post-traumatic arthritis, insufficient x-rays, or a sacroiliac joint that could not be visualized on film. Data collected included age and BMI. PT was calculated using the formula, Tilt = -(ln((B/A) x (1/0.483)))/0.051. Value A is the distance from the base of the SI joint to the superior margin of the obturator foramen; value B is the height of the obturator foramen. ResultsMean preoperative PT was 0.2° versus intraoperative PT was 3.4° (p < 0.001). Mean absolute difference was 6.5°. 48% of patients (n = 81) had an absolute difference less than 5°, 31% (n = 52) between 5° and 10°, 14% (n = 24) between 10° and 15°, and 7% (n = 12) greater than 15°. There was no correlation between BMI or age and PT discrepancy. ConclusionOf the patients, 21% had a discrepancy of 10° or greater between their preoperative radiographs and intraoperative fluoroscopic images. Surgeons should be aware of potential errors in cup positioning and be particularly diligent in high-risk cases.

Radiological outcomes following surgical fixation with wires versus moulded cast for patients with a dorsally displaced fracture of the distal radius: a radiographic analysis from the DRAFFT2 trial.

The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient's initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function.

Optimizing vestibular implant electrode positioning using fluoroscopy and intraoperative CT imaging

Purpose Vestibular implant electrode positioning close to the afferent nerve fibers is considered to be key for effective and selective electrical stimulation. However, accurate positioning of vestibular implant electrodes inside the semicircular canal ampullae is challenging due to the inability to visualize the target during the surgical procedure. This study investigates the accuracy of a new surgical protocol with real-time fluoroscopy and intraoperative CT imaging, which facilitates electrode positioning during vestibular implant surgery.Methods Single-center case-controlled cohort study with a historic control group at a tertiary referral center. Patients were implanted with a vestibulocochlear implant, using a combination of intraoperative fluoroscopy and cone beam CT imaging. The control group consisted of five patients who were previously implanted with the former implant prototype, without the use of intraoperative imaging. Electrode positioning was analyzed postoperatively with a high-resolution CT scan using 3D slicer software. The result was defined as accurate if the electrode position was within 1.5 mm of the center of the ampulla.ResultsWith the new imaging protocol, all electrodes could be positioned within a 1.5 mm range of the center of the ampulla. The accuracy was significantly higher in the study group with intraoperative imaging (21/21 electrodes) compared to the control group without intraoperative imaging (10/15 electrodes), (p = 0.008).Conclusion The combined use of intraoperative fluoroscopy and CT imaging during vestibular implantation can improve the accuracy of electrode positioning. This might lead to better vestibular implant performance.

Sacroiliac joint fusion guided by intraoperatively superimposed virtual surgical planning using simulated fluoroscopic images

IntroductionSacroiliac joint fusion (SIJF) is a minimally invasive treatment for sacroiliac (SI) dysfunction. It involves placing implants through the SI joint under fluoroscopic guidance, requiring precise implant positioning to avoid nerve injury. Preoperative virtual surgical planning (VSP) aids in optimal positioning, but replicating it accurately in the operating room is challenging. Research questionThis study aims to assess the feasibility of superimposing VSP onto intraoperative fluoroscopic images to aid in optimal implant placement. Material and methodsA method for intraoperative guidance using 3D/2D registration was developed and tested during SIJF as an available and potentially efficient alternative for costly and more invasive navigation systems. Preoperatively, a VSP is performed and simulated fluoroscopic images are generated from a preoperative CT scan. During surgery, the simulated image that visually best matches the intraoperative fluoroscopic image is selected. Subsequently, the VSP is superimposed onto the intraoperative fluoroscopic image using a developed script-based workflow. The surgeon then places the implants accordingly. Postoperative implant placement accuracy was evaluated. ResultsFive interventions were performed on five patients, resulting in a total of 15 placed implants. Minor complications without clinical consequences occurred in one case, primarily attributable to the patient's anatomy and pathological manifestations. Mean deviations at implant apex and 3D angle were 4.7 ± 1.6 mm and 3.5 ± 1.3°, respectively. Discussion and conclusionsThe developed intraoperative workflow was feasible and resulted in implants placed with low deviations from the VSP. Further research is needed to automate and validate this method in a larger cohort.

Artificial intelligence- and computer-assisted navigation for shoulder surgery.

Background: Over the last few decades, shoulder surgery has undergone rapid advancements, with ongoing exploration and the development of innovative technological approaches. In the coming years, technologies such as robot-assisted surgeries, virtual reality, artificial intelligence, patient-specific instrumentation, and different innovative perioperative and preoperative planning tools will continue to fuel a revolution in the medical field, thereby pushing it toward new frontiers and unprecedented advancements. In relation to this, shoulder surgery will experience significant breakthroughs. Main body: Recent advancements and technological innovations in the field were comprehensively analyzed. We aimed to provide a detailed overview of the current landscape, emphasizing the roles of technologies. Computer-assisted surgery utilizing robotic- or image-guided technologies is widely adopted in various orthopedic specialties. The most advanced components of computer-assisted surgery are navigation and robotic systems, with functions and applications that are continuously expanding. Surgical navigation requires a visual system that presents real-time positional data on surgical instruments or implants in relation to the target bone, displayed on a computer monitor. There are three primary categories of surgical planning that utilize navigation systems. The initial category involves volumetric images, such as ultrasound echogram, computed tomography, and magnetic resonance images. The second type is based on intraoperative fluoroscopic images, and the third type incorporates kinetic information about joints or morphometric data about the target bones acquired intraoperatively. Conclusion: The rapid integration of artificial intelligence and deep learning into the medical domain has a significant and transformative influence. Numerous studies utilizing deep learning-based diagnostics in orthopedics have remarkable achievements and performance.

Accuracy of imaging grading in comparison to open laminectomy to evaluate pedicle screws positioning.

Prospective experimental study. To compare the accuracy of O-Arm-acquired radiographic and computed tomography (CT) evaluation of thoracic pedicle screw placement with open laminectomy in a simulation laboratory. Improving surgical safety and procedural efficiency during thoracic posterior spine instrumentation is essential for decreasing complication rates and possible related risks. The most common way of verifying the position of pedicle screws during the surgical procedure and immediately postoperatively is to acquire intraoperative fluoroscopic images and plain radiographs of the spine, respectively. Laboratory simulated surgery is a valuable tool to evaluate the accuracy of those exams. Twenty simulation models of scoliosis from T3 to T7 were instrumented by five spine fellows (total of 200 pedicle screws), followed by radiographic and CT images acquired with the assistance of the O-Arm which were evaluated by three independent raters. A fellowship-trained spine neurosurgeon performed laminectomies on the instrumented levels and assessed pedicle integrity (gold standard). Forty-eight breaches were identified in the axial direct view after laminectomy. Of those, eighteen breaches were classified as unacceptable. Regarding the sagittal direct view, four breaches were observed, three of which were classified as unacceptable. Overall, both O-arm radiographic and CT evaluations had a significantly high negative predicted value but a low positive predicted value to identify unacceptable breaches, especially in the sagittal plane. The frequency of missed breaches by all three examiners was high, particularly in the sagittal plane. Postoperative evaluation of pedicle screws using O-arm-acquired radiographic or CT images may underdiagnose the presence of breaches. In our study, sagittal breaches were more difficult to diagnose than axial breaches. Although most breaches do not have clinical repercussions, this study suggests that this modality of postoperative radiographic assessment may be inaccurate. 4.

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft