Intraoperative Fluoroscopy Time Research Articles

A Comparative Study of a New Retractor-Assisted WILTSE TLIF, MIS-TLIF, and Traditional PLIF for Treatment of Single-Level Lumbar Degenerative Diseases.

ObjectivesTo compare the clinical efficacy of a new retractor‐assisted Wiltse transforaminal lumbar interbody fusion (TLIF), minimally invasive TLIF (MIS‐TLIF), and traditional posterior lumbar interbody fusion (PLIF) in treating single‐level lumbar degenerative diseases.MethodsA retrospective study was conducted by analyzing the clinical and imaging data of consecutive patients with single‐level lumbar degenerative diseases who underwent the new retractor‐assisted Wiltse TLIF, MIS‐TLIF, or traditional PLIF. This study enrolled 87 concurrent patients between June 2016 and December 2019 (Wiltse TLIF 29 cases; MIS‐TLIF 28 cases; PLIF 30 cases). The three groups were compared for perioperative indicators (including intraoperative blood loss, postoperative drainage volume, operation time, intraoperative fluoroscopy time, bedridden time), creatine kinase (CK), visual analog score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score, intervertebral fusion rate, muscle atrophy, and fatty infiltration (including ratio of multifidus atrophy and ratio of lean‐to‐total cross‐sectional area [CSA]).ResultsIntraoperative blood loss (F = 62.628, p < 0.001), postoperative drainage volume (F = 72.048, p < 0.001), and bedridden time (χ2 = 62.289, p < 0.001) were significantly lower in the MIS‐TLIF and Wiltse groups than in the PLIF group. The operative and intraoperative radiation times of the MIS‐TLIF group were significantly longer than those of the Wiltse and PLIF groups. The CK concentration in the Wiltse and MIS‐TLIF groups were significantly lower than those in the PLIF group 1 day (F = 9.331, p < 0.001) and 3 days after surgery (F = 15.967, p < 0.001). The PLIF group's back pain VAS score was higher than those of the Wiltse and MIS‐TLIF groups. The PLIF group had a higher ODI 6 months (F = 3.282, p = 0.042) and 12 months (F = 5.316, p = 0.007) after surgery and a lower JOA score than the Wiltse and MIS‐TLIF groups 6 months (F = 3.234, p = 0.044) and 12 months (F = 3.874, p = 0.025) after surgery. The ratio of multifidus atrophy in the PLIF group (41.70 ± 8.84%) was significantly higher than those of the Wiltse group (24.13 ± 6.82%) and the MIS‐TLIF group (22.35 ± 5.03%). The ratio of lean‐to‐total CSA in the PLIF group was lower than those of the Wiltse and MIS‐TLIF groups after surgery (F = 8.852, p < 0.001). MIS‐TLIF group showed longer operation time (169.11 ± 29.38 min) and intraoperative fluoroscopy time (87.61 ± 3.13 s) than the Wiltse group.ConclusionWiltse TLIF assisted by the new retractor is a more convenient and minimally invasive surgical method than the traditional PLIF and MIS‐TLIF methods, which are linked to a long learning curve and long operation and fluoroscopy time.

Effect of Different Anesthesia and Puncture Methods of Percutaneous Kyphoplasty on More Than 90-Year-Old Osteoporotic Vertebral Fracture: Advantages of the ERAS Concept.

Background Percutaneous kyphoplasty (PKP) is an effective minimally invasive technique for the treatment of osteoporotic vertebral fracture (OVF) in recent years. This study focuses on the analysis of PKP surgery and anesthesia in osteoporotic vertebral facture patients over 90 years old with the concept of “enhanced recovery after surgery.” Methods This study reviewed 239 patients who were diagnosed with OVF retrospectively between October 2015 and June 2019. According to the method of anesthesia, these patients were divided into Group A (n = 125) and Group B (n = 114). According to the pedicle puncture approach, these patients were divided into Group C (n = 102) and Group D (n = 137). The anterior vertebral height (AVH) and local kyphosis angle (LKA) were used to evaluate the degree of vertebral damage and restoration. The visual analogue scale (VAS) and the Oswestry Disability Index (ODI) scores were used for assessing functional outcomes. Some parameters were used to assess the perioperative conditions such as operation time, amount of bone cement perfusion, intraoperative fluoroscopy times, anesthesia recovery time, time out of the bed, hospital stay, hospitalization cost, and complications. Results The visual analogue scale (VAS), Oswestry Disability Index (ODI), anterior vertebral height (AVH), and local kyphosis angle (LKA) 1 day, 1 year after surgery, and at the last follow-up all showed significant improvement (P < 0.05) in comparison with those before surgery both in Groups A and B and Groups C and D. The ODI 1 day after surgery was significantly better in Group B than Group A (P < 0.05). Compared with Group B, Group A required longer time of anesthesia, operation time, anesthesia recovery time, time to get out of bed, and length of hospital stay and more hospitalization costs (P < 0.05). Group D required longer operation time, longer time to get out of bed, more bone cement volume, fluoroscopy time, and more operation hospitalization costs compared with Group C (P < 0.05). Conclusion We recommend unilateral puncture under local anesthesia for OVF in the patients aged over 90 from the perspective of rapid recovery.

Pelvic Osteotomy in Patients With Previous Sacral-Alar-Iliac (SAI) Fixation.

Patients with neuromuscular disease are at high risk for developing hip dysplasia and scoliosis. The purpose of this study was to investigate the technical challenges and outcomes of pelvic osteotomy in patients with prior sacral-alar-iliac (SAI) fixation. We reviewed clinical and radiographic records of patients aged 18 years and below who underwent pelvic osteotomy after SAI fixation. We recorded technical challenges during the osteotomy, time from SAI fixation to osteotomy, type of osteotomy, migration index, and distance from the SAI screw to the acetabulum. A 2-sample Wilcoxon rank-sum test was used to assess the data. Nineteen patients were included. Technical challenges were defined as having greater intraoperative fluoroscopy times and noted difficult osteotomy in the operative report. The mean time from SAI fixation to pelvic osteotomy was 2.2±1.5 years. For all 12 Chiari osteotomies, the ilium could not be laterally displaced; however, medial displacement of the distal segment of the osteotomy allowed adequate coverage. All 7 Dega osteotomies were performed by cutting the cortex at the tip of the SAI screw. The screw improved proximal leverage and provided a strong buttress for bone graft. The mean migration index before pelvic osteotomy was 59±19%, and at most recent follow-up was 13±4%. Twelve patients, who had a noted complicated osteotomy, had SAI screws that were ≤1.87 cm ( P <0.01) from the acetabulum and significantly increased intraoperative fluoroscopy time (1.76 vs. 1.18 min, P <0.01). The presence of SAI screws may cause iliac osteotomies to be technically challenging if the tip of the SAI screw is ≤1.87 cm to the acetabulum. When initially implanting SAI screws in neuromuscular patients, surgeons should attempt to place screw tips ∼2 cm from the acetabulum in the event these patients require subsequent pelvic osteotomy. Level IV.

Effect analysis of trajectory screw technique in fragility fracture of pelvic ring

To assess the clinical efficacy of minimally invasive technology with trajectory screw fixation for fragility fractures of pelvic(FFP). A retrospective case control study was performed to analyze the clinical data of 35 patients with FFP who were treated and followed up between January 2016 and December 2019. There were 12 males and 23 females, aged from 65 to 99 years with an average of(75.4±7.8) years old. There were 13 cases of type Ⅱb, 7 cases of type Ⅱc, 8 cases of type Ⅲa, 2 cases of type Ⅲb, 2 cases of type Ⅲc, 1 case of type Ⅳb, and 2 cases of type Ⅳc according to Rommens FFP comprehensive classification. All patients received the treatment of minimally invasive technology with trajectory screws fixation. According to the different methods of anterior pelvic ring fixation, FFP patients were divided into two groups:12 cases were fixed with the pedicle screw rod system in the anterior pelvic subcutaneous internal fixator (INFIX) group;23 cases were fixed with hollow screws of the pubic symphysis, superior ramus of pubis or acetabular anterior column in the screw group. The operation time, intraoperative blood loss, intraoperative fluoroscopy times, length of hospital stay, cost of internal fixation, pre- and post-operative visual analogue scale(VAS) were compared between the two groups. The fracture reduction quality was evaluated according to the Matta criteria, and the clinical function was evaluated by the Majeed functional scoring system respectively. All patients were followed up for 12 to 39(16.5±5.4) months after surgery. There was no statistically significant difference in the operation time, intraoperative blood loss, intraoperative fluoroscopy time, and length of hospital stay between the two groups(P>0.05). As for the cost of internal fixation, the cost of internal fixation in the screw group [2 914 (2 914, 4 371) yuan] was significantly lower than that of the INFIX group [6 205 (6 205, 6 205) yuan] (P<0.05). No significant difference was observed in the incidence of postoperative complications between the two groups (P>0.05). There was no significant difference in VAS assessment at admission, 1 week, and 3 months after surgery between the two groups(P>0.05). However, the VAS assessment at 1 week and 3 months after surgery of the two groups were significantly better than those at admission(P<0.05). There was no significant difference in the quality of fracture reduction after the operation and the efficacy evaluation at the last follow-up between the two groups(P>0.05). For the treatment of fragility fractures, minimally invasive technology with trajectory screw fixation can achieve good clinical efficacy. It has the advantages of being relatively minimally invasive, less bleeding, relieving the pain. It deserves clinical application.

Posterior INFIX for Treating Unilateral Unstable Sacral Fractures.

ObjectiveTo evaluate the clinical outcomes of the treatment of unilateral unstable sacral fractures by fixation with the posterior INFIX (posterior pelvic ring screw‐rod internal fxation).MethodsData of 60 patients with unilateral unstable sacral fractures who underwent surgery from March 2013 to March 2020 were retrospectively analyzed according to the selection criteria. All patients were associated with anterior pelvic ring injuries, and the operations were performed by the same team of surgeons. According to the different types of internal fixation, the patients were divided into two groups, which both included 30 patients: the posterior INFIX group and iliosacral screw fixation group. The demographic and clinical data of the two patient groups, such as age, sex, sacral fracture types based on the Denis classification, operation time, amount of intraoperative bleeding, intraoperative fluoros copy time, Majeed pelvic score at final follow‐up, and quality of fracture reduction based on Mears and Velyvis's imaging classification criteria were collected by the same researcher and compared statistically.ResultsAll patients were continuously followed up for 23.17 ± 3.34 months (range, 12 to 46 months). All sacral fractures healed with an average healing time of 9.3 ± 2.24 months (range, 6 to 18 months). None of the patients had re‐displacement of the fracture or fixation failure. Compared to the iliosacral screw group, the posterior INFIX group patients had more intraoperative bleeding (t = 3.59, P < 0.001), shorter operation time (t = 4.49, P < 0.001), and shorter intraoperative fluoroscopy time (t = 6.26, P < 0.001). There were no statistical differences between the two groups in terms of age, sex, fracture type, Majeed score, and quality of fracture reduction (P > 0.05). In the posterior INFIX group, one patient had a superficial wound infection and one patient complained of discomfort due to a prominent fixation. In the iliosacral screw fixation group, one patient had intraoperative iatrogenic S1 nerve injury and vessel injury. The posterior INFIX fixation was a simpler manipulation with higher safety, shorter time of operation and intraoperative fluoroscopy, and similar clinical outcomes compared to iliosacral screw fixation.ConclusionFor the treatment of unilateral unstable sacral fractures, the posterior INFIX fixation can be recommended in clinic application.

Comparison of femoral neck system to multiple cancellous screws and dynamic hip screws in the treatment of femoral neck fractures

ObjectiveTo compare the short-term outcomes of the femoral neck system (FNS) with multiple cancellous screws (MCS) and dynamic hip screws (DHS) in the treatment of femoral neck fractures. MethodsA retrospective analysis was performed on 157 patients with fresh femoral neck fractures treated with FNS (from September 2019 to October 2020), MCS, and DHS (from January 2018 to October 2020). According to internal fixation methods, all patients were divided into the FNS group (54 cases), MCS group (51 cases), and DHS group (52 cases). Demographic data were also collected, recorded, and compared, including the follow-up time, days of hospitalization, operation time, blood loss, intraoperative fluoroscopy times (IFT), weight-bearing time (WBT), length of femoral neck shortening (LFNS), Harris hip score, and complications (such as internal fixation failure, bone nonunion, and avascular necrosis of the femoral head) between the three groups. ResultsOverall, 157 patients with a mean age of 61.8 (range, 18–89) years were analyzed. In the FNS group, IFT (median 10.5) was significantly lower than that in the MCS group (median 21) and DHS group (median 20.5) (P<0.05), and WBT was significantly earlier than that of the MCS group (P<0.05). In the FNS group, the median hospitalization time, operation time, and blood loss were 2 (2, 4) days, 45 (40–59) min, and 30 (20, 50) ml, respectively. They were all significantly less than 3.5 (3, 6) days, 72 (55–88.75) min, and 50 (30, 50) ml in the DHS group, respectively (P < 0.05). There was no statistical difference in LFNS, quality of reduction, internal fixation failure rate, and Harris hip score at the latest follow-up (P>0.05). No surgical complications such as incision infection, deep infection, pulmonary embolism, or femoral head necrosis were found in any of the three groups. ConclusionFNS, MCS, and DHS are all effective for femoral neck fractures. However, a lower IFT of FNS shortens the operation time. Compared to MCS, FNS has the advantages of being a simple operation, with early WBT; compared to DHS, a minimally invasive operation is the main advantage of FNS.

A case-control study of minimally invasive transforaminal interbody fusion with the assistance of robot and traditional fluoroscopy in the treatment of single-space lumbar disc herniation

To compare the safety and nail placement accuracy of fluoroscopy-assisted and robot-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of single-space lumbar disc herniation. The clinical data of 52 patients with single-space lumbar disc herniation treated by MIS-TLIF from March 2019 to February 2020 were retrospectively analyzed. Among them, 24 patients were treated by robot-assisted MIS-TLIF(group A) and 28 patients were treated by fluoroscopy-assisted MIS-TLIF (group B). The intraoperative blood loss, operation time, intraoperative fluoroscopy times, preoperative and postoperative visual analogue scale(VAS), Japanese Orthopaedic Association(JOA) scores and operation-related complications were recorded in two groups. Gertzbein-Robbins grade according to CT scan was used to evaluate the nail placement after operation. Grade A and B were evaluated as satisfactory nail placement, and grade C, D, and E were evaluated as error placement. Babu's method was used to evaluate the screw's invasion to the superior articular process. The operation time, intraoperative blood loss and intraoperative fluoroscopy times in group A were less than those in group B(P<0.05).VAS and JOA scores of all patients at the final follow-up were significantly improved compared with those before operation(P<0.05), but there was no statistically significant difference between the groups(P>0.05). There were 96 and 112 screws in group A and group B, respectively. Three days after operation, according to the Gertzbein-Robbins grade to evaluate the nail placement accuracy, there were 90 screws of grade A, 5 of grade B, 1 of grade C, no grade D and E in group A;there were 84 screws of grade A, 16 of grade B, 8 of grade C, 4 of grade D, no grade E in group B;the difference between two groups was statistically significant(Z=-3.709, P=0.000). The satisfactory rate of screw placement in group A was 98.96% (95/96), and that of group B was 89.29% (100/112), the difference between two groups was statistically significant (χ2=8.254, P=0.004). Three days after operation, the invasion of superior facet joints by pedicle screws was evaluated according to Babu's method, including 90 screws in grade 0, 4 in grade 1, 2 in grade 2, and 0 in grade 3 in group A;86 in grade 0, 12 in grade 1, 10 in grade 2 and 4 in grade 3 in group B, and the difference was statistically significant(Z=-3.433, P=0.001). There were no serious spinal cord, nerve and vascular injuries and other operation-related complications caused by screw implantation failure in both groups. All patients were followed up from 6 to 12(9.06±1.60) months. The neurological symptoms improved well after operation. During the follow-up period, there was no recurrence of symptoms, loosening or breakage of the internal fixation. Compared with the traditional fluoroscopy-assisted MIS-TLIF, the spinal robot-assisted MIS-TLIF not only has more minimally invasive and safer, but also has higher accuracy in nail placement, lower incidence of upper articular process invasion, and more accurate decompression targets, which can be used for minimally invasive treatment of single-space lumbar disc herniation.

Accuracy and safety of robot assisted pedicle screw placement

To investigate the accuracy and safety of pedicle screw placement assisted by orthopedic robot and C-arm fluoroscopy. The clinical data of 36 patients with spinal diseases underwent surgical treatment from January 2019 to August 2020 was retrospectively analyzed. Among them, 18 cases were implanted pedicle screws assisted by orthopaedic robot(observation group), including 12 males and 6 females, aged from 16 to 61 years with an average of (38.44±3.60) years;there were 1 case of adolescent scoliosis, 1 case of spinal tuberculosis, 7 cases of lumbar spondylolisthesis, 4 cases of thoracic fracture and 5 cases of lumbar fracture. Another 18 cases were implanted pedicle screws assisted by C-arm fluoroscopy(control group), including 10 males and 8 females, aged from 18 to 58 years with an average of (43.22±2.53) years;there were 1 case of adolescent scoliosis, 6 cases of lumbar spondylolisthesis, 6 cases of thoracic fracture and 5 cases of lumbar fracture. The intraoperative fluoroscopy times, nail placement time and postoperative complications were recorded in two groups. CT scan was performed after operation. The Gertzbein-Robbins standard was used to evaluate the accuracy of pedicle screw placement which was calculated. The number of intraoperative fluoroscopy in observation group was(6.89±0.20) times, which was significantly higher than that in control group(14.00±0.18)times(P<0.05). The placement time of each screw in observation group was(2.56±0.12) min, which was significantly different from that in control group(4.22±0.17) min (P<0.05). One case of incision infection occurred in control group after operation, and recovered after active dressing change. During the follow-up period, no serious complications such as screw loosening and fracture occurred in two groups, and there was no significant difference in complications between two groups(P>0.05). A total of 107 screws were placed in observation group, including 101 screws in class A, 4 in class B, 2 in class C, 0 in class D and 0 in class E, the accuracy rate of pedicle screw placement=[(number of screws in class A+B) / the number of all screws placed in the group] ×100%=98.1%(105/107); and a total of 104 screws were placed in control group, including 90 screws in class A, 4 in class B, 5 in class C, 5 in class D and 0 in class E, the accuracy rate of pedicle screw implantation=[(number of screws in class A+B/the number of all screws placed in the group]×100%=90.3% (94/104); there was significant difference between two groups (P<0.05). Orthopaedic robot assisted pedicle screw placement has the advantages of less fluoroscopy times, shorter screw placement time and higher accuracy, which can further improve the surgical safety and has a broad application prospect in the orthopaedic.

Would your intraoperative results differ if you were a four-handed orthopedist in intramedullary nail surgery for tibial fractures?

The present study aimed to present the intraoperative results of a fixation device that assists in fracture reduction during closed intramedullary nail application in tibial shaft fractures and provides a temporary stable fixation until the last stage of surgery. The fixation device used in our study consists of two custom-made bone clamps and a joint system that connects the clamps. Patients diagnosed with closed tibial shaft fracture between 01.01.2020 and 20.12.2021 were included in our retrospective study. Twenty-one patients who underwent closed intramedullary nailing and used a fixation device in the intraoperative period (Group 1) and 21 patients who underwent closed intramedullary nailing without a fixation device (Group 2) were included in the study. Both groups were compared in terms of duration of the operation, amount of bleeding, wound infection, intraoperative fluoroscopy time, preoperative period, follow-up time, varus and valgus deformity, limb shortness, malrotation, nonunion, and deep vein thrombosis. In Group 1, the mean duration of operation was 72.62±8.78minutes; the mean amount of bleeding was 31.10±6.13ml, and the mean intraoperative fluoroscopy time was 76.81±11.83 s. In Group 2, the mean duration of operation was 87±13.12 minutes; the mean amount of bleeding was 29.81±6.01ml and the mean intraoperative fluoroscopy time was 100.71±11.50 s. Intraoperative fluoroscopy time, varus deformity, and malrotation were significantly different between the groups (p=0.001, p=0.030, p=0.001, respectively). In the study, it was observed that the intraoperative fixation device decreased intraoperative fluoroscopy time, varus, and rotational deformity. It was considered that the fixation device would reduce the radiation exposure of the health personnel in the intraoperative period and reduce the malunion rate due to varus and rotational deformity.

Effect of Different Reduction Intramedullary Nails on Spiral Fracture of Middle and Lower Tibia.

Objective To compare the efficacy of different reduction and intramedullary nailing in the treatment of spiral fracture of middle and lower tibia. Method A total of 96 patients with spiral fractures of middle and lower tibia treated with intramedullary nails were retrospectively analyzed. The patients were divided into closed functional reduction group, open anatomical reduction group, and closed anatomical reduction group according to different treatment methods. The operation time, intraoperative blood loss, intraoperative fluoroscopy times, fracture healing time, fracture nonunion, wound complications, and healing conditions of the three groups were compared. Results The operation time and intraoperative fluoroscopy times of patients in the closed anatomical reduction group were significantly increased compared with those in the closed functional reduction group, while the fracture healing time was significantly reduced. However, patients in the open reduction group had significantly more intraoperative blood loss than those in the closed reduction group. The mean follow-up duration of patients was 15.81 ± 3.25 months. Open anatomical reduction was found to have a higher complication rate during follow-up. Specifically, a total of 3 cases recovered after 2 times of surgical treatment. 6 cases showed a small gap at the fracture end which did not affect the function. Conclusion In the treatment of middle and lower spiral fracture of tibia, closed anatomical reduction and intramedullary nail internal fixation have shorter fracture healing time, less blood loss, and fewer complications, which can act as the first surgical choice. However, open reduction and intramedullary nailing have a high complication rate, which is not recommended.

A follow up study on the treatment of tibial fractures with intramedullary interlocking nail through the suprapatellar approach

To investigate the short-term effect of suprapatellar interlocking intramedullary nail in the treatment of tibial fractures. Eighty patients with tibial fractures treated from January 2016 to June 2018 were treated with interlocking intramedullary nail, who were divided into observation group (suprapatellar approach) and control group (patellar ligament approach) according to different surgical approaches. There were 40 cases in the observation group, including 28 males and 12 females, aged 28 to 67 years with a mean of (46.70±10.34) years. There were 40 cases in the control group, including 30 males and 10 females, aged 31 to 69 years with a mean of(49.38±10.74) years. The operation time, incision length, intraoperative C-arm X-ray fluoroscopy times, intraoperative blood loss, fracture healing time, postoperative active straight leg raise (SLR) time, hospital stay, visual analogue scale (VAS), knee pain rate and postoperative Hospital for Special Surgery (HSS) score were recorded and compared between two groups. All the patients were followed up, and the duration ranged from 19 to 38 months, with an average of(24.60±4.52) months. In the observation group, the operation time was(53.83± 7.01) min;the incision length was (3.98±0.83) cm;the number of intraoperative C-arm X-ray fluoroscopy was (18.90±1.75) times;the fracture healing time was (10.03±0.89) weeks;the postoperative active SLR time was (1.19±0.25) days;and the hospital stay was(6.73±1.06) days. The above indexes were better than those in the control group (P<0.05). In the latest follow-up, 34 cases got an excellent result, 5 good, 1 fair and 0 poorin the observation group. In the control group, 25 cases got an excellent result, 9 good, 6 fair and 0 poor. The curative effect of the observation group was better than that of the control group(P< 0.05). The treatment of tibial fractures with suprapatellar interlocking intramedullary nail has the advantages of less trauma and better recovery of knee function. It can obtain more satisfactory clinical results and can be further widely used.

Novel Minimally-Invasive Triple Pelvic Osteotomy: JiShuiTan Minimally-Invasive Approach.

Triple pelvic osteotomy (TPO) is often performed to improve femoral head coverage, correct deformity, and stabilize the hip joint in a variety of pediatric orthopaedic conditions. After the TPO was first reported, many modifications were developed to simplify or improve the procedure, however, because of the specific anatomy with several critical nerves and vessels passing through the approaches, extensive exposure and prolonged intraoperative fluoroscopy are often required for TPO. This report introduces a novel, minimally-invasive surgical approach that minimizes the time of intraoperative fluoroscopy and size of the surgical incision, and reviews our experience. A total of 48 hips in 43 patients with a mean age of 8.3±1.7 years (range: 6.0 to 12.2 y) were included in this study. Of these, 21 patients (22 hips) had Legg-Calvé-Perthes disease (LCPD) and 22 patients (26 hips) had developmental dysplasia of the hip (DDH). The TPOs were performed using the novel, minimally-invasive TPO approach, with a mean postoperative follow-up of 38 months (range: 24 to 54 mo) in the DDH group and 44 months (range: 23 to 58 mo) in the LCPD group. The acetabular index (AI), femoral head migration rate (MP), center edge angle (CEA) and the Severin and Stulberg classification systems were used to evaluate the preoperative and postoperative results. SPSS software was used to analyze the data. The AI decreased from 33.8 degrees±9.2 to 2.9 degrees±10.1, the lateral CEA increased from -10.8 degrees±23.8 to 34.1 degrees±9.9, and the femoral head MP decreased from 64.0%±19.8% to 1.1%±2.6% in the DDH group at last follow-up, indicating significant improvement. The AI decreased from 20.8 degrees±4.7 to -1.3 degrees±7.3, the lateral CEA increased from 6.8 degrees±11.5 to 42.3 degrees±6.4, and the femoral head MP decreased from 42.2%±13.0% to 1.3%±3.3% in the LCPD group at last follow-up, also indicating significant improvement. This approach can simplify the TPO, making the complex operation safer, more effective, and capable of achieving satisfactory correction.

Radiation educational program significantly reduces intraoperative fluoroscopy time during locking plate fixation for distal radius fractures

BackgroundThe use of C-arm fluoroscopy poses a risk of radiation exposure to the surgeons. This study aimed to examine the intraoperative fluoroscopy time of the distal radius plating before and after radiation educational program. MethodsA total of 68 cases (48 women and 20 men; average age, 61.8 years) were reviewed between July 2017 and October 2019. All patients were treated with volar locking plate fixation for distal radius fractures. On October 2018, we had a 1-h radiation educational program for orthopedic surgeons. Intraoperative fluoroscopy time was compared between 34 cases in the preintervention group (group A) and 34 cases in the postintervention group (group B). Radiographic correction loss of the fracture was assessed by ulnar variance (UV), radial inclination (RI), and volar tilt (VT) between immediately after surgery and at the time of bone union. ResultsA significant difference was found in intraoperative fluoroscopy time between 329 s in group A and 123 s in group B. ΔUV between immediately after surgery and at the time of bone union was 0.6 mm in group A and 0.3 mm in group B; ΔRI was −0.3° in group A, −0.1° in group B, ΔVT is −0.4° in group A, and −0.1° in group B. No significant difference was found among them. ConclusionsAfter an educational program on radiation exposure, the intraoperative fluoroscopy time was significantly saved in the plating surgery for the distal radius fractures. The shortening of the intraoperative fluoroscopy time did not affect the loss of radiographic correction of the fractures.

Comparison of novel machine vision spinal image guidance system with existing 3D fluoroscopy-based navigation system: a randomized prospective study

BACKGROUND CONTEXTThe use of spinal image guidance systems (IGS) has increased patient safety, accuracy, operative efficiency, and reduced revision rates in pedicle screw placement procedures. Traditional intraoperative 3D fluoroscopy or CT imaging produces potentially harmful ionizing radiation and increases operative time to register the patient. An IGS, FLASH Navigation, uses machine vision through high resolution stereoscopic cameras and structured visible light to build a 3D topographical map of the patient's bony surface anatomy enabling navigation use without ionizing radiation. PURPOSEWe aimed to compare FLASH navigation system to a widely used 3D fluoroscopic navigation (3D) platform by comparing radiation exposure and pedicle screw accuracy. DESIGNA randomized prospective comparative cohort study of consecutive patients undergoing open posterior lumbar instrumented fusion. PATIENT SAMPLEAdults diagnosed with spinal pathology requiring surgical treatment and planning for open posterior lumbar fusion with pedicle screws implanted into 1-4 vertebral levels. OUTCOME MEASURESOutcome measures included mean intraoperative fluoroscopy time and dose, mean CT dose length product (DLP) for preoperative and day 2 CT, pedicle screw accuracy by CT, estimated blood loss and revision surgery rate. METHODSConsecutive patients were randomized 1:1 to FLASH or 3D and underwent posterior lumbar instrumented fusion. Radiation doses were recorded from pre- and postoperative CT and intraoperative 3D fluoroscopy. 2 independent blinded radiologists reviewed pedicle screw accuracy on CT. RESULTSA total of 429 (n=210 FLASH, n=219 3D) pedicle screws were placed in 90 patients (n=45 FLASH, n=45 3D) over the 18-month study period. Mean age and indication for surgery were similar between both groups, with a non-significantly higher ratio of males in the 3D group.Mean intraoperative fluoroscopy time and doses were significantly reduced in FLASH compared to 3D (4.51±3.71s vs 79.6±23.0s, p<.001 and 80.9±68.1cGycm2 vs 3704.1±3442.4 cGycm2, p<.001, respectively). This represented a relative reduction of 94.3% in the total intraoperative radiation time and a 97.8% reduction in the total intraoperative radiation dose. Mean preoperative CT DLP and mean day 2 postoperative CT DLP were significantly reduced in FLASH compared to 3D (662.0±440.4mGy-cm vs 1008.9±616.3 mGy-cm, p<.001 and 577.9±294.3 mGy-cm vs 980.7±441.6 mGy-cm, p<.001, respectively). This represented relative reductions of 34.4% and 41.0% in the preoperative CT dose and postoperative total DLP, respectively.The FLASH group required an average of 1.2 registrations in each case with an average of 2447 (±961.3) data points registered with a mean registration time of 106s (±52.1). A rapid re-registration mechanism was utilized in 22% (n=10/45) of cases and took 22.7s (±11.3). Re-registration was used in 7% (n=3/45) in the 3D group.Pedicle screw accuracy was high in FLASH (98.1%) and 3D (97.3%) groups with no pedicle breach >2mm in either group (p<.001). EBL was not statistically different between the groups (p=.38). No neurovascular injuries occurred, and no patients required return to theatre for screw repositioning. CONCLUSIONSFLASH and 3D IGS demonstrate high accuracy for pedicle screw placement. FLASH showed significant reduction in intraoperative radiation time and dose with lower but non-significant blood loss. FLASH showed significant reduction in preoperative and postoperative radiation, but this may be associated to the lower number of males/females preponderance in this group. FLASH provides similar accuracy to contemporary IGS without requiring 3D-fluoroscopy or radiolucent operating tables. Reducing registration time and specialized equipment may reduce costs.

Treatment of humeral shaft fractures: a new minimally-invasive plate osteosynthesis versus open reduction and internal fixation: a case control study

BackgroundTo evaluate the feasibility and safety of a new minimally-invasive surgical approach–anteromedial minimally-invasive plate osteosynthesis (MIPO)–in the treatment of middle and distal humeral shaft fractures.MethodsFourteen patients with humeral shaft fracture treated with anteromedial MIPO from November 2016 to March 2020 (MIPO Group) were selected as the study subjects. Open reduction and internal fixation (ORIF) were used to treat 14 patients with humeral shaft fractures as the control group (ORIF group). The two groups were fixed with a locking compression plate (LCP) or LCP + multi-directional locking screw system (MDLS). The incision length, intraoperative blood loss, intraoperative fluoroscopy time, operation time, length of hospital stay, fracture healing time, QuickDASH score and Constant score were observed and compared between the two groups.ResultsFourteen patients were enrolled in each group. The incision length (7.79 ± 2.39 cm), intraoperative blood loss (96.07 ± 14.96 mL), operative time (110.57 ± 21.90 min), hospital stay (6.29 ± 1.49 days) and fracture healing time (14.94 ± 0.99 weeks) in the MIPO group were all lower than those in the ORIF group, and the difference was statistically significant for each parameter (P < 0.05). The intraoperative fluoroscopy time (20.07 ± 3.22) in the MIPO group was significantly higher than that in the ORIF group (P < 0.05). There were no significant differences in age (P = 0.078), QuickDASH score (P = 0.074) or Constant score (P = 0.293) between the two groups and no postoperative complications occurred in any of the patients.ConclusionThe anteromedial approach MIPO technique has the advantages of less trauma, less bleeding, low risk of nerve injury and high rate of fracture healing. It is one of the most effective methods for the treatment of middle and middle–distal humeral shaft fractures.

Comparative Analysis of Non-Full and Full Endoscopic Spine Technique via Interlaminar Approach for the Treatment of Degenerative Lumbar Spinal Stenosis: A Retrospective, Single Institute, Propensity Score-Matched Study.

Retrospective study. To compare the clinical efficacy of posterior lumbar laminectomy decompression under full endoscopic technique (Endo-LOVE) and percutaneous endoscopic medial foraminal decompression (PE-MFD) in the treatment of degenerative lumbar spinal stenosis (DLSS). Between April 2017 and April 2018, 96 patients with DLSS underwent Endo-LOVE or PE-MFD, including 58 with Endo-LOVE and 38 with PE-MFD. After propensity score matching (PSM), patient characteristics, operation time, intraoperative fluoroscopy times, postoperative bedridden time, hospital stay and postoperative complications were recorded and compared. The clinical efficacy was evaluated according to Oswestry disability index (ODI), visual analogue scale (VAS), lumbar disease JOA and modified MacNab criteria. A total of 96 patients with DLSS were included in the study. After PSM, the 2 groups were comparable in patient demographic and baseline characteristics. The operation time and intraoperative fluoroscopy times in PE-MFD group were significantly more than those in Endo-LOVE group (P < .05). The operation time in PE-MFD group was significantly less than that in Endo-LOVE group (P < .05).The intraoperative fluoroscopy times in PE-MFD group were significantly more than that in Endo-LOVE group (P < .05). The ODI, VAS and lumbar disease JOA in the 2 groups were significantly improved comparing with those before operation (P < .05). According to the modified MacNab criteria, the excellent and good rates of the 2 groups were 93.5% in Endo-LOVE group and 87.1% in PE-MFD group (P > .05). Endo-LOVE and PE-MFD technique can both effectively treat DLSS, and the short-term follow-up results are positive. Endo-LOVE technique has the advantages of fast puncture positioning, less radiation exposure and wider indications. However, PE-MFD needs more radiation exposure and has the possibility of incomplete decompression for complex multiplanar spinal stenosis.

Effectiveness of synchronous unilateral percutaneous kyphoplasty in the treatment of double noncontiguous thoracolumbar osteoporotic vertebral compression fractures

To investigate the effectiveness of synchronous unilateral percutaneous kyphoplasty (PKP) in the treatment of double noncontiguous thoracolumbar osteoporotic vertebral compression fracture (OVCF). Between December 2018 and September 2020, 27 patients with double noncontiguous thoracolumbar OVCF were treated by synchronous unilateral PKP. There were 11 males and 16 females, with an average age of 75.4 years (range, 66-92 years). The fractures were caused by falls in 22 cases and sprains in 5 cases. The time from injury to hospital admission was 0.5-7.0 days, with an average of 2.1 days. The fractured vertebrae located at T 9 in 2 cases, T 10 in 3 cases, T 11 in 10 cases, T 12 in 15 cases, L 1 in 12 cases, L 2 in 6 cases, L 3 in 4 cases, and L 4 in 2 cases. The volume of bone cement injected into each vertebral body, operation time, and intraoperative fluoroscopy times were recorded. Anteroposterior and lateral X-ray films of thoracolumbar spine were taken to observe the anterior height of the injured vertebra, the Cobb angle of kyphosis, and the diffusion and good distribution rate of bone cement in the thoracolumbar spine. Visual analogue scale (VAS) score and Oswestry disability index (ODI) were used to evaluate the pain and functional improvement. All operations completed successfully. The operation time was 34-70 minutes, with an average of 45.4 minutes. The intraoperative fluoroscopy was 21- 60 times, with an average of 38.6 times. The volume of bone cement injected into each vertebral body was 2-9 mL, with an average of 4.3 mL. All patients were followed up 6-21 months, with an average of 11.3 months. X-ray film reexamination showed that the anterior height of the injured vertebra and Cobb angle at each time point after operation were significantly improved than those before operation ( P<0.05), and there was no significant difference between different time points after operation ( P>0.05). The distribution of bone cement was excellent in 40 vertebral bodies, good in 13 vertebral bodies, and poor in 1 vertebral body, and the excellent and good rate was 98.1% (53/54). The pain of all patients significantly relieved or disappeared, and the function improved. The VAS score and ODI at each time point after operation were significantly lower than those before operation ( P<0.05), and there was no significant difference between different time points after operation ( P>0.05). For the double noncontiguous thoracolumbar OVCF, the synchronous unilateral PKP has the advantages of simple puncture, less trauma, less intraoperative fluoroscopy, shorter operation time, satisfactory distribution of bone cement, etc. It can restore the height of the vertebral body, correct the kyphotic angle, significantly alleviate the pain, and improve the function.

Bilateral percutaneous balloon kyphoplasty through unilateral transverse process-extrapedicular approach for osteoporotic vertebral compression fracture of lumbar

To evaluate the feasibility and short-term effectiveness of bilateral percutaneous balloon kyphoplasty through unilateral transverse process-extrapedicular approach for osteoporotic vertebral compression fracture (OVCF) of lumbar. A retrospective analysis was made on the clinical data of 93 patients with OVCF of lumbar who met the selection criteria between January 2018 and June 2019. According to the different surgical methods, they were divided into group A (44 cases, treated with bilateral percutaneous balloon kyphoplasty through unilateral transverse process-extrapedicular approach) and group B [49 cases, treated with percutaneous kyphoplasty (PKP) via bilateral transpedicle approach]. There was no significant difference in gender, age, body mass index, T value of bone mineral density, injury cause, fractured level, time from injury to operation, comorbidities, and preoperative Cobb angle of injured vertebra, visual analogue scale (VAS) score, and Oswestry disability index (ODI) between the two groups ( P>0.05). The operation time, intraoperative fluoroscopy times, bone cement injection amount, and incidence of bone cement leakage were recorded and compared between the two groups; Cobb angle of the injured vertebrae, VAS score, and ODI were measured before operation, at 2 days and 1 year after operation. The contralateral distribution ratio of bone cement was calculated according to the anteroposterior X-ray film at 2 days after operation. The operation time and the intraoperative fluoroscopy times in group A were significantly less than those in group B ( P<0.05). There was no bone cement adverse reactions, cardiac and cerebrovascular adverse events, and no complications such as puncture needles erroneously inserted into the spinal canal and nerve injuries occurred in the two groups. Bone cement leakage occurred in 6 cases and 8 cases in groups A and B, respectively, all of which were asymptomatic paravertebral or intervertebral leakage, and no intraspinal leakage occurred; the bone cement injection amount and incidence of bone cement leakage between the two groups showed no significant differences ( P>0.05). The contralateral distribution ratio of bone cement in group A was significantly lower than that in group B ( t=2.685, P=0.009). Patients in both groups were followed up 12-20 months, with an average of 15.3 months. The Cobb angle of the injured vertebrae, VAS score, and ODI in the two groups were significantly improved at 2 days after operation, however, the Cobb angle of the injured vertebra at 1 year after operation was significantly lost when compared with the 2 days after operation, the VAS score and ODI at 1 year after operation were significantly further improved when compared with the 2 days after operation, the differences were all significant ( P<0.05). There was no significant difference in the Cobb angle of the injured vertebrae, VAS score, and ODI between the two groups at each time point after operation ( P>0.05). Bilateral percutaneous balloon kyphoplasty through unilateral transverse process-extrapedicular approach is comparable to bilateral PKP in short-term effectiveness with regard to fracture reduction, reduction maintenance, pain relief, and functional improvement. It has great advantages in reducing operation time and radiation exposure, although it is inferior in bone cement distribution.

85. Comparison of novel machine vision image guidance system with a 3D fluoroscopy-based platform for pedicle screw placement: a randomized prospective study of radiation, accuracy, and cost

<h3>BACKGROUND CONTEXT</h3> The use of image guidance and robotics platforms has increased patient safety, accuracy and operative efficiency and reduced revision rates during pedicle screw placement procedures. However, traditional intraoperative 3D or computational tomography (CT) imaging produces potentially harmful ionizing radiation and increases operative time to register the patient. An image guidance platform using machine vision through high resolution stereoscopic cameras and structured visible light does not use ionizing radiation while it builds a 3D topographical map of the patient's anatomy for navigation use. <h3>PURPOSE</h3> We aimed to compare a novel machine vision image guidance system (MvIGS) system to a widely used 3D fluoroscopy (3D) platform by comparing radiation exposure, and pedicle screw accuracy. <h3>STUDY DESIGN/SETTING</h3> A randomized prospective comparative cohort study of consecutive patients undergoing posterior lumbar instrumented fusion. <h3>PATIENT SAMPLE</h3> Adults diagnosed with a spinal condition requiring surgical treatment and planning to have posterior open lumbar fusion with pedicle screws implanted into 1-4 vertebral levels. <h3>OUTCOME MEASURES</h3> Outcome measures included: mean intraoperative fluoroscopy time and dose, mean preoperative CT dose length product (DLP) and mean day 2 postoperative CT DLP, pedicle screw accuracy and rate of revision surgery. <h3>METHODS</h3> Patients were randomized 1:1 to MvIGS or 3D and underwent posterior lumbar instrumented fusion. Radiation doses were recorded from pre- and postoperative CT and intraoperative fluoroscopy. Independent blinded radiologists reviewed pedicle screw accuracy. <h3>RESULTS</h3> A total of 303 (154 MvIGS, 149 3D) pedicle screws were placed in 63 patients (33 MvIGS, 30 3D) over the 12-month study period. Mean age and indication for surgery were similar between both groups. Mean intraoperative fluoroscopy time and doses were significantly reduced in MvIGS compared to 3D (5.2±4.1s vs 79.6±23.3s, p<0.001 and 133.0±215.8cGycm2 vs 3704.1±1640.5cGycm2, p<0.001, respectively). This represents a relative reduction of 93.5% in the total intraoperative time and 96.4% reduction in the total dose. Mean preoperative CT DLP and mean day 2 postoperative CT DLP were significantly reduced in MvIGS compared to 3D (590.8±389.6mGy*cm vs 1008.9±616.3mGy*cm, p<0.001 and 518.1±205.6mGy*cmvs 958.7±449.6mGy*cm, p<0.001, respectively). This represents a relative reduction of 41.4% and 46.0% relative reduction in the preoperative CT dose and postoperative total DLP, respectively. The MvIGS group required an average of 1.2 registrations each case with an average of 2447 (SD=961.3) data points registered with mean registration time of 106s (SD=52.1s). A rapid re-registration mechanism was utilized in 22% (n=7/33) of cases. Pedicle screw accuracy was high in both groups MvIGS (98.7%) vs 3D (97.3%) with no pedicle breach >2mm in either group (p>0.001). No neurovascular injuries occurred, and no patients needed return to theatre for screw repositioning. <h3>CONCLUSIONS</h3> Both MvIGS and 3D image guidance platforms demonstrated high accuracy for pedicle screw placement. MvIGS demonstrated significant reduction of 93.5% and 96.4% in intraoperative radiation time and dose. MvIGS may provide similar accuracy to contemporary image guidance platforms without requiring 3D fluoroscopy or radiolucent operating tables. Reducing registration times and the need for specialized equipment may significantly reduce operating room costs. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Modified Microcoil for Preoperative Localization of Solitary Pulmonary Nodules: A Prospective, Single-Arm, Multicenter Clinical Study

PurposeTo evaluate the efficacy and safety of placement of a modified microcoil for precise preoperative localization of solitary pulmonary nodules (SPNs) before video-assisted thoracoscopic surgery (VATS). Materials and MethodsThis prospective, single-arm, multicenter study included patients who underwent computed tomography (CT)-guided modified microcoil insertion prior to SPN resection by VATS between January 2018 and June 2018. The patient demographics, nodule characteristics, and histopathologic findings were recorded. The primary endpoints included efficacy and safety. ResultsA total of 96 patients (41 men and 55 women; mean age, 59.3 years ± 8.9) with 96 SPNs were eligible for enrolment in the study. The mean maximal transverse diameter of the nodules was 10.3 mm ± 5.2 (range, 8–20 mm). The mean time between CT-guided microcoil insertion and the start of the surgical procedure was 14.6 hours (range, 12–24 hours). The duration of the preoperative CT-guided microcoil localization procedure was 29 minutes ± 9 (range, 10–35 minutes), and the intraoperative fluoroscopy time was 0.7 minutes ± 0.7 (range, 0.5–3 minutes). The clinical success rate was 96.9% (93/96), and all nodules were successfully resected using VATS. One patient experienced asymptomatic pneumothorax, but there were no cases of pulmonary hemorrhage. ConclusionsSPN localization with the modified microcoil is feasible and safe. The modified microcoil can facilitate the thoracoscopic resection of SPNs.