Intraoperative Radiographs Research Articles

Artificial Intelligence-Based Surgery Support Model Using Intraoperative Radiographs for Assessing the Acetabular Component Angle

BackgroundThis study aimed to develop an artificial intelligence–based surgical support model for assessing the acetabular component angle using intraoperative radiographs during total hip arthroplasty and verify its accuracy. MethodsA total of 268 hips were analyzed. At first, 268 preoperative and intraoperative anteroposterior pelvic radiographs were amplified to 536. These radiographs were used to create a learning model to estimate the acetabular component angle from the radiographs intraoperatively. The ground truth was the anteversion and inclination angles obtained from the computed tomography–based navigation system intraoperatively. Bone landmarks on the preoperative and intraoperative radiographs were manually annotated. The distances and angles between each landmark were used as predictor variables. The estimation accuracy was assessed for internal and external test datasets. Mean absolute error (MAE) and R2 values were used as accuracy measures. ResultsThe MAE and R2 for the internal test set showed 2.19 and 0.850 for anteversion, and 1.18 and 0.805 for inclination, respectively. The MAE and R2 for the external test set showed 2.78 and 0.789 for anteversion, and 1.56 and 0.744 for inclination, respectively. ConclusionsWe developed an artificial intelligence–based surgical support model for accurately assessing the acetabular component angle using intraoperative radiographs. Excellent estimation accuracy was confirmed for the external test set. In the future, the model may help to reduce the risk of adverse postoperative events.

Length and offset restoration in partial hip arthroplasty (PHA) performed by resident surgeons: Comparison between preoperative planning and intraoperative X-ray.

Restoring of leg length and femoral offset in partial hip arthroplasty (PHA) performed by residents (level one of experience surgery) in the neck femoral fractures has a significant role in the clinical outcome. The aim of this study is to show the statistically significant differences in restoring hip geometric parameters using preoperative planning vs intraoperative X-ray. Authors compared the use of pre-operative planning with intra-operative radiography to restore the limb length and femoral offset, focused on the measurement of femoral offset and leg length discrepancy (LLD). Based on the calculation of the sample size, the number of observations required for each test group was 37 patients. For all patients were performed pre- and post-operative measurements, using mediCAD HECTET GmbH Version 5.0 software, calibrated after positioning of a radiographic landmark of 25,4 mm. The median post-operative LLD was substantially overlapping between the two group patients (1 mm vs. 1,5 mm). Statistical analyses did not find a statistically significant difference between the using of preoperative planning and intra-operative x-ray according to postoperative LLD (p = 0,06). Similarly, median change in the offset did not differ between the two groups (-2 mm vs. -1,5 mm; p = 0.69). In our experience, the combined use of pre- and intraoperative techniques appear to be viable and effective in order to restore femoral offset and minimize LLD.

Quantifying Radiographs in Endodontics: A Survey

Purpose: The aim of this study was to investigate the average quantity of radiographs obtained during non-surgical endodontic treatment and trends in endodontic radiography among U.S. members of the AAE. Materials & Methods: A survey was sent via e-mail to 4,269 active U.S. members of the AAE. Data were collected over a period of approximately 4 months. The number of radiographs reported for non-surgical endodontic treatment was compared across fourteen variables using Kruskal Wallace tests. Chi Square tests of Independence were also used to evaluate trends in endodontic radiography based on three primary categorical variables of interest: years of experience, professional role (PR) and use of CBCT technology. Results: 412 responses were collected (response rate ~10%). 98.3% of respondents were endodontists while the remaining 1.7% were endodontics residents. 96.1% of respondents reported the use digital radiography, 98.1% use CBCT, 87.1% of respondents reported always using an Electronic Apex Locator (EAL), and only 29.4% of respondents reported using any type of handheld x-ray system. 54.4% reported always taking intra-operative (IO) radiographs. Most respondents selected 6-7 and 8-12 radiographs to be excessive. Kruskal Wallace tests confirmed statistically significant differences between the quantity of radiographs acquired and the categorical variables (i.e., PR, years of experience, the quantity of radiographs respondents reported to be excessive, and the type of radiography used while in residency (conventional vs. digital). The average number of radiographs acquired during non-surgical endodontic treatment was 3 (anterior), 4 (premolar) and 4 (molar). Chi Squared Tests of Independence revealed significant trends in endodontic radiography based on respondents’ PR, years of experience, and use of CBCT technology. Conclusion: There were statistically significant differences in the average quantity of radiographs obtained during non-surgical endodontic treatment amongst respondents of varying PR and years of experience. The use of adjunct technology, type of radiography, and preferred positioning device did not significantly impact the number of radiographs completed. The average number of radiographs acquired during non-surgical endodontic treatment was higher for premolars and molars than anterior teeth.

Fragmented acupuncture needle as a linear metallic foreign body near the proximal interphalangeal joint of a horse.

To describe the clinical presentation, diagnosis, and treatment of a fragmented, migrating acupuncture needle near the palmar proximal interphalangeal joint (PIPJ) of a horse. A 9-year-old Warmblood cross mare. The mare presented for evaluation of a linear metallic foreign body on the palmar lateral aspect of the PIPJ following acupuncture treatment. The mare had a pinpoint puncture wound and sensitivity to palpation over the lateral aspect of the PIPJ region. The referring veterinarian performed radiographs and found a linear metallic foreign body near the lateral palmar PIPJ. Ultrasonographic examination demonstrated a hyperechoic lesion consistent with a metallic object in the soft tissues of the palmar lateral aspect of the PIPJ. The horse was anesthetized, and the linear metallic foreign body was removed. The use of intraoperative ultrasound and digital radiographs assisted in determining the location of and surgical approach to remove the foreign body. The linear metallic foreign body was the fragmented segment (body) of an acupuncture needle. The mare recovered from surgery uneventfully and returned to the previous level of activity. This report demonstrates the potential risks of prolonged retention and or delayed removal of acupuncture needles in the form of needle fragmentation and migration. It also demonstrates the use of imaging in determining the location and position of small, thin metallic foreign bodies to aid in surgical approach and removal.

Patient reported outcomes after revision ankle fixation

BackgroundFunctional outcome following ankle fracture fixation is linked to the restoration of joint congruity, anatomic alignment and stability. If surgical fixation fails to achieve these goals, revision surgery may be indicated. This retrospective study aims to report a consecutive series of fourteen patients with a minimum of one year follow up after revision ankle fixation and describe CT scan based modified Pettrone score used to assess quality of primary fixation. MethodsBetween April 2019 and August 2021, fourteen patients underwent revision ankle fracture fixation. Patients were identified by the multidisciplinary team through a review of intra-operative radiographs. Subsequently, a CT scan-based criteria which is modification of original Pettrone criteria based on plain radiographs was applied to further assess sub-optimal fixation. Demographic, clinical, radiological and patient-reported outcome measures data were collected and examined. ResultsTwelve patients exhibited protonation type injuries according to the Lauge-Hansen classification system. Syndesmotic joint was readdressed in eleven patients. The mean duration between the index surgery and the subsequent revision surgery was 46 days (inter-quartile range – 42 days). The mean Olerud-Molander Ankle Score was calculated as 58, with an IQR of 45. Similarly, the mean EQ-5D-3L VAS score was determined to be 69, with an IQR of 35. In our series, 60 % patients reported good to excellent results using OMAS. The quality-of-life scores of in these patients were also satisfactory. ConclusionWe recommend early revision fixation should be considered when primary fixation is considered inadequate in early post-operative period. The modified Pettrone criterion can be used to assess sub-optimal fixation.

How to be sure of a complete removal of Essure® implant? A radiological study of Essure® microinserts

PurposeLaparoscopic cornuectomy, one of the most performed surgical techniques to remove Essure® implants, is associated with a risk of fragmentation of the device. We aimed to assess the diagnostic accuracy of the intraoperative radiograph of the removed Essure® microinserts compared with intraoperative inspection of the device. Study designIn this French retrospective cohort study including 66 patients, two experienced gynecologists and two residents evaluated the intraoperative radiograph in a blind manner. Diagnostic accuracy was calculated for each observer. ResultsThe global sensitivity and specificity for intraoperative radiograph to detect a residual fragment for both senior gynecologists and residents were, respectively 87.5 % (±3.3) and 80.0 % (+/12.2). Pooled positive (PPV) and negative predictive values (NPV) for intraoperative radiograph were respectively 99.2 % (±0.5) and 21.6 % (±6.4). There was a statistically significant difference in intraoperative radiograph analysis between senior gynecologists and residents (sensitivity: 91.4 %±0.8 vs 79.6 %±1.5, p = 0.02; specificity: 100% vs 50.0 %, p < 0.0001; PPV: 100 % vs 98.0 % ±0.1, p = 0.0007; NPV: 26.8 % ±1.8 vs 7.2 % ±0.5, p = 0.009).Sensitivity and specificity of the intraoperative inspection of the removal specimen was respectively 95.3 % and 100 % (PPV and NPV were, respectively 100 and 40 %).There were no statistically significant differences in diagnostic accuracy between intraoperative radiographs analysis and intraoperative inspection of the device for the senior gynecologists. ConclusionsIntraoperative radiograph of the removed Essure® implants analysis is a difficult skill needing specific training. Postoperative pelvic X-ray is still recommended in clinical practice after laparoscopic cornuectomy.

Does levelling of T1 tilt intra-operatively affect post-operative shoulder balancein adolescent idiopathic scoliosis patients?

Previous studies have shown that T1 tilt is positively correlated with post-operative shoulder balance (SB). The aim of this study was to explore the role of intra-operative T1 tilt, among other shoulder parameters as a potential parameter to predict post-operative SB in adolescent idiopathic scoliosis (AIS) patients. A retrospective review of AIS patients with structural thoracic curves with minimum 2year follow up was conducted from a single tertiary center. Standing pre-operative, 1st erect, 1year and 2-year follow-up; and intra-operative final prone radiographs were reviewed along with clinical data. Patients were stratified into 2 cohorts: Group A-Final intra-operative T1 tilt ≤5° and Group B-Final intra-operative T1 tilt >5°. These groups were compared for post-operative SB as a whole and separately for patients with baseline right or left shoulder high and if UIV was T2 or T3/T4. Patients with optimal SB (Radiographic shoulder height (RSH) <2cm) at 2years were compared to sub-optimal SB (RSH ≥ 2cm) with respect to multiple SB variables. 55 patients (mean age 15.1years-old, 43 F, mean BMI 22, mean thoracic Cobb-49.8°) were included. Based on Lenke curve types, there were 13 patients with type 1A, 10 patients with 1B, 12 patients with 1C, 7 patients with 2A, 4 patients with 2B and 9 patients with type 3C. T1 tilt was significantly correlated with RSH, Clavicle angle difference (CAD), First Rib Angle (FRA), and UIV tilt at first erect, 1-year, and 2-year post-op radiographs (p < 0.05 for all). When comparing groups, A and B, Group A patients showed significantly better restoration of their 2-year SB parameters; RSH (6.8 vs 11.8mm, p = 0.01), CAD (3.9 vs 9.1 p < 0.001) and T1 tilt (4.7 vs 7.8° p = 0.01). Similar results were found for patients with baseline right shoulder high; RSH (p = 0.04), CAD (p < 0.001) and T1 tilt (p < 0.001) and whether UIV was T2 or T3/T4. Eight patients with sub-optimal SB had worse intra-operative T1 tilt (p = 0.03) compared to 47 patients with optimal SB despite no difference in MT Cobb correction (83.1 vs 79.8%, p = 0.57). Post-operative T1 tilt correlates with lateral shoulder parameters at first erect, 1year, and 2-year radiographs. Therefore, T1 tilt can potentially be used as a surrogate to predict post-operative SB. Leveling intra-operative T1 tilt ≤5° is associated with better 2-year post-operative shoulder balance parameters irrespective of whether the UIV was T2 or T3/T4. Patients with sub-optimal SB at 2years had worse final intra-operative T1 tilt despite similar percent correction of main thoracic curve for all patients.

Anterioposterior Views Coupled With Lateral Views Are the Best for the Intraoperative Radiographic Detection of Retained Surgical Sponges.

A retained sponge after spine surgery can cause serious medical complications and medicolegal problems. Intraoperative radiographs are commonly used to detect it. This study evaluated intraoperative radiographs under routine clinical conditions that most spine surgeons experience to detect retained sponges. In this prospective randomized clinical trial, two patient groups undergoing open posterior lumbar surgery were studied. In one, a sponge was intentionally present; in the other, none was present. Standard intraoperative lateral (LAT) and anteroposterior (AP) radiographs were acquired before closing. Radiographs were analyzed for sensitivity, specificity, inter- and intraobserver reliability for three viewing conditions: one LAT radiograph versus one AP radiograph versus one LAT and one AP X-ray (LAT+AP). A total of 111 patients were included. Accuracy, interobserver reliability, and intraobserver reliability were best for LAT+AP (80%, 96%, and 96%, respectively). Sensitivity was best for LAT+AP (87%) and specificity was best for LAT (95%). Positive predictive value was best for LAT (94%); negative predictive value was best for LAT+AP (88%). The probability of being right is better for female sex (odds ratio 1.6), younger age (odds ratio 1.02), and higher BMI (odds ratio 1.06). We recommend AP with LAT images rather than either an AP or a LAT image alone.

Equine cheek tooth repulsion using small diameter repulsion pins: 20 cases.

Reported complication rates after dental repulsion for equine exodontia are high (up to 80%), but repulsion methods have changed notably in the last 20 years. Describe the outcome for 20 cases after dental repulsion using small diameter repulsion pins. Retrospective case series. Records of horses that underwent cheek tooth repulsion were reviewed (2014-2023). Inclusion criteria included: mandibular or maxillary cheek tooth extraction where oral extraction failed and repulsion was used to complete extraction, and where clinical follow up information was available. Repulsions were carried out under sedation with a regional nerve block or under a short general anaesthetic, using a small diameter repulsion pin (3-5 mm). Intra-operative radiographs facilitated instrument placement. The alveolus was packed with polymethyl methacrylate post-extraction. Horses were re-examined at 4-6 weeks post-operatively. Twenty cases were included. Patients had a mean age of 10.3 years old (range 5-16 years). The majority (75%) of teeth had pre-existing dental fractures. Maxillary (n = 15) and mandibular cheek teeth (n = 5) were all successfully repulsed, with 16 cases performed with the horse standing and 4 with the horse under general anaesthesia. Intra-operative complications included damage to the mandibular bone (n = 1). Short-term complications (n = 2) included superficial surgical site infection, and dehiscence of one sinus flap. Long-term complications included the recurrence of sinusitis (n = 1) and small intra-alveolar fragments causing persistent bitting problems in another patient. Retrospective study design, small number of cases. When oral extraction fails, cheek tooth repulsion using small diameter repulsion pins is an effective extraction technique. The total intra- and post-operative complication rate was 25%, which is comparable to previously published complication rates for repulsion using Steinmann pins and also those encountered after trans-buccal screw extraction.

A MORPHOLOGICAL REVIEW OF MEDIAL MALLEOLAR FRACTURES: ARE THERE ANY FACTORS WHICH MAY PREDISPOSE TO NONUNION AND MALUNION?

BackgroundMany approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion.MethodsPatients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records in a single centre. Analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology.ResultsA total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). There was no significant difference in union rates across the Herscovici classification groups. Herscovici type A fractures were significantly more frequently malreduced at time of surgery as compared to other fracture types (p=.003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who have been anatomically reduced.ConclusionThe morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions however the clinical implications of mal reducing small avulsions is unknown.

Immediate Postoperative Change in the Upper Instrumented Screw-Vertebra Angle Is a Predictor for Proximal Junctional Kyphosis and Failure.

Retrospective review. To determine if change in position of upper instrumented vertebral (UIV) screw between intraoperative prone and immediate postoperative standing radiographs is a predictor for proximal junctional kyphosis or failure (PJK/PJF). Cranially directed UIV screws on post-operative radiographs have been found to be associated with PJK. Change in the screw position between intraoperative and immediate postoperative radiographs has not been studied. Patients with posterior fusion ≥3 levels and UIV at or distal to T8, and minimum 2-year follow-up were identified from a single center database. Primary outcomes were radiographic PJK/PJF or revision for PJK/PJF. Demographic, surgical and radiographic variables, including intraoperative screw-vertebra (S-V) angle, change in S-V angle, direction of UIV screw (cranial-neutral-caudal) and rod-vertebra (R-V) angle were collected. 143 cases from 110 patients were included with a mean age of 62.9 years and a follow-up of 3.5 years. 54 (38%) cases developed PJK/PJF, of whom 30 required a revision. Mean S-V angle was -0.9°±5.5° intraoperative and -2.8°±5.5° postoperative. The group with PJK/PJF had a mean S-V angle change of -2.5°±2.4 while the rest had a change of -1.0°±1.6 (P=0.010). When the change in S-V angle was <5°, 33% developed PJK, this increased to 80% when it was ≥5° (P=0.001). Revision for PJK/PJF increased from 16% to 60% when S-V angle changed ≥5° (P=0.001). Regression analysis showed S-V angle change as a significant risk factor for PJK/PJF (P=0.047, OR=1.58) and for revision due to PJK/PJF (P=0.009, OR=2.21). Change in the S-V angle from intraop prone to immediate postop standing radiograph is a strong predictor for PJK/PJF and for revision. For each degree of S-V angle change, odds of revision for PJK/PJF increases by 2.2x. A change of 5° should alert the surgeon to the likely development of PJK/PJF requiring revision.

Design and Evaluation of Kirschner Wire Guide Device for Patellar Fracture Fixation

Abstract Identifying the optimal position for Kirschner wire (K-wire) is crucial in tension band wiring for patellar fracture. This study analyzed the ideal position and designed a guide device to aid precise K-wire insertion. The stress and displacement at 90&amp;amp;amp;#176; of flexion were compared to determine the optimal positions. The number of insertions and fluoroscopies, and operating times were recorded in a retrospective study. Intraoperative radiographs were used to measure the K-wire position relative to the patella in the coronal and sagittal planes to assess accuracy. The least stability occurred when the distance between the K-wires was 1/2 of the patellar width in the coronal plane and close to the patellar anterior surface. The number of K-wire insertions in the experimental group and control group (1.33 ±0.58 vs 3.8 ±1.03; P = 0.009), the number of fluoroscopies (2.67 ±0.58 vs 10 ±1.33; P = 0.007), and the operating time (55 ±8.66 min vs 82 ±9.49 min; P = 0.001) were significantly different. K-wires should parallel to each other, spaced 1/4 or 1/3 of the patellar width in the coronal plane, and 1/2 to 3/4 of the patellar thickness in the sagittal plane away from the patellar anterior surface. The surgeon could improve insertion accuracy with guide device.

Virtual reality training for intraoperative imaging in orthopaedic surgery: an overview of current progress and future direction

Trauma and orthopedic surgery commonly rely on intraoperative radiography or fluoroscopy, which are essential for visualizing patient anatomy and safely completing surgical procedures. However, these imaging methods generate ionizing radiation, which in high doses carries a potential health risk to patients and operating personnel. There is an established need for formal training in obtaining precise intraoperative imaging while minimizing radiation exposure. Virtual reality (VR) simulation serves as a promising tool for orthopaedic trainees to develop skills in safe intraoperative imaging, without posing harm to patients, operating room staff, or themselves. This paper aims to provide a brief overview of literature surrounding VR training for intraoperative imaging in orthopaedic surgery. In addition, we discuss areas for improvement and future directions for development in the field.

The tibial capsular reflection and septum in posterior compartment are safe and reliable soft-tissue landmark for tibial tunnel drilling in posterior cruciate ligament reconstruction.

To investigate the validity of using tibial capsular reflection and septum in the posterior compartment as landmark during posterior cruciate ligament (PCL) reconstruction (PCLR). Anatomic measurements were obtained for 12 fresh human cadaveric knee specimens to observe the spatial position of the tibial insertion of the PCL in relation to the posterior septum and the capsular reflection in the posterior compartment. Sixty patients who underwent reconstruction of the PCL between 2020 and 2023 were also retrospectively investigated. The tibial tunnel was replaced in all patients using the same method (with reference to the tibial capsular reflection and the posterior septum). The placement of the tibial tunnel was assessed using X-ray fluoroscopy intraoperatively and computed tomography and three-dimensional reconstruction postoperatively. All fibres in the tibial insertion of the PCL in the 12 cadaveric specimens were located in the posteromedial compartment, adjacent to the posterior septum. The inferior border of the PCL insertion is adjacent to the tibial capsular reflection, which is attached at the champagne glass drop-off of the posterior tibia. In our previous cases, none of the patients experienced postoperative or intraoperative complications such as neurovascular injury, and the angle between the pin and the PCL facet was 93.1 ± 3.9° as measured on intraoperative radiographs. The mean distance from the centre of the tibial tunnel outlet to the inferior border of the PCL insertion was 5.6 ± 1.1 mm, and the distance from the centre of the tibial tunnel outlet to the outer border of the PCL insertion as a percentage of the length of the inferior border of PCL insertion was 42.2 ± 6.3%. The tibial capsular reflection and septum in the posterior compartment are safe and reliable soft-tissue landmark for tibial tunnel drilling in PCLR. Level Ⅳ.

A magnet foreign body in the vermiform process in a child aged two years and eight months

BACKGROUND: Foreign bodies in the gastrointestinal tract is a fairly common pathology in pediatric surgery. The proportion of all cases is about 80%; in 20% of cases, foreign bodies can stuck in the physiological colon narrowings and in 0.005% — in the appendix. It is thought that magnetic foreign bodies pose a danger, if they are two or more because they can be attracted to each other at different parts of the gastrointestinal tract. A foreign body can get into the vermiform process, if its mass exceeds the mass of caecum content. Under the gravity mechanism, the foreign body penetrates into the dilated appendix lumen, but lumen peristalsis may not be strong enough to push it back into the large intestine. Swallowed foreign bodies may be asymptomatic in the vermiform process, and can manifest clinically as the inflammation either after few hours or after many years. CLINICAL CASE DESCRIPTION: In patient X., aged 2 years and 8 months, a magnet foreign body (a piece of magnetic pen) got into the vermiform process. The independent discharge of this object was under control, but no results. Patient's general state was satisfactory. No pathologies were observed in organs and systems. After a series of X-ray examinations of the abdominal organs, suspicion appeared that this foreign body was in the appendix. Diagnostic laparoscopy with intraoperative radiography and then laparoscopic appendectomy were performed. Macropreparation: unchanged vermiform process 6 cm long. The appendix lumen was opened, a foreign body was found — a magnetic rod with size 0.5 cm x 0.2 cm. CONCLUSION: The postoperative period was uneventful. The child was discharged from the hospital in the recovering state after the performed surgical intervention — an elective laparoscopic appendectomy.

Attitude and Perceptions of Healthcare workers regarding ionizing radiation

IntroductionIn operating rooms, the routine use of radiological procedures is commonplace. However, this essential tool brings about significant concerns for healthcare workers due to the associated radiological risks. Understanding healthcare workers’ attitudes and perceptions about ionizing radiation is crucial for addressing these concerns.ObjectivesThis study aims to assess the perceptions and concerns of healthcare workers regarding radiation risks and their practices in the operating room.MethodsA cross-sectional study was conducted in February and March 2023 among the operating room staff of Habib Bourguiba University Hospital in Sfax, Tunisia. We used a self-administered questionnaire that included socio-professional data. Self-assessment of exposure risk and protection level against ionizing radiation was evaluated on a scale from 0 to 10, and attitudes were assessed using a 5-item Likert scale.Results Our study population consisted of 92 healthcare workers, with 54.3% being male. When asking operating room workers about the availability, accessibility, and quality of lead aprons, the median scores were 3 (IQR [0;6.5]), 2 (IQR [0;5]), and 2 (IQR [0;5]), respectively. The median self-assessment score for exposure risk was 8 (IQR [5.5; 10]), while the median self-assessment score for protection against ionizing radiation was 1 (IQR [0;3]). Sixty percent of the population had limited knowledge of the harmful effects of ionizing radiation, with a median self-assessment knowledge score of 1.5 (IQR [0;3]). Sixty-two percent reported concerns regarding radiological risks. In terms of practices, 44.5% of the staff maintained a distance from the radiation source during intraoperative radiography, and 21.7% used the apron for protection. Dosimeters were not used by any of the participants. Concerns level was associated with self-assessment of exposure risk (p = 0.027).ConclusionsIn conclusion, awareness of the risks generates anxiety and concern among staff; however, it alone is insufficient to alter our practices. This underscores the imperative for a proactive approach in implementing robust safety measures and comprehensive training programs.Disclosure of InterestNone Declared

Three-dimensional printed models can reduce costs and surgical time for complex proximal humeral fractures: preoperative planning, patient satisfaction, and improved resident skills

BackgroundProximal humeral fractures (PHFs) are still controversial with regards to treatment and are difficult to classify. The study’s objective is to show that preoperative planning performed while handling a three-dimensional (3D) printed anatomical model of the fracture can ensure a better understanding of trauma for both surgeons and patients.Materials and methodsTwenty patients (group A, cases) with complex PHF were evaluated preoperatively by reproducing life-size, full-touch 3D anatomical models. Intraoperative blood loss, radiographic controls, duration of surgery, and clinical outcomes of patients in group A were compared with 20 patients (group B, controls) who underwent standard preoperative evaluation. Additionally, senior surgeons and residents, as well as group A patients, answered a questionnaire to evaluate innovative preoperative planning and patient compliance. Cost analysis was evaluated.ResultsIntraoperative radiography controls and length of operation were significantly shorter in group A. There were no differences in clinical outcomes or blood loss. Patients claim a better understanding of the trauma suffered and the proposed treatment. Surgeons assert that the planning of the definitive operation with 3D models has had a good impact. The development of this tool has been well received by the residents. The surgery was reduced in length by 15%, resulting in savings of about EUR 400 for each intervention.ConclusionsFewer intraoperative radiography checks, shorter surgeries, and better patient compliance reduce radiation exposure for patients and healthcare staff, enhance surgical outcomes while reducing expenses, and lower the risk of medicolegal claims.Level of evidenceLevel I, prospective randomized case–control study.

Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis.

Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

Formal Radiologist Interpretations of Intraoperative Spine Radiographs Have Low Clinical Value.

Retrospective cohort. To evaluate the clinical relevance, usefulness, and financial implications of intraoperative radiograph interpretation by radiologists in spine surgery. Due to rising healthcare costs, spine surgery is under scrutiny to maximize value-based care. Formal radiographic analysis remains a potential source of unnecessary healthcare costs, especially for intra-operative radiographs. A retrospective cohort analysis was performed on all adult elective spine surgeries at a single institution between July 2020 and July 2021. Demographic and radiographic data was collected, including intraoperative localization and post-instrumentation radiographs. Financial data was obtained through the institution's price estimator. Radiographic characteristics included time from radiographic imaging to completion of radiologist interpretation report, completion of radiologist interpretation report prior to the conclusion of surgical procedure, clinical relevance, and clinical usefulness. Reports were considered clinically relevant if spinal level of the procedure was described and clinically useful if completed prior to conclusion of the procedure and deemed clinically relevant. 481 intraoperative localization and post-instrumentation radiographs from 360 patients revealed a median delay of 128 minutes between imaging and completion of interpretive report. Only 38.9% of reports were completed before conclusion of surgery. There were 79.4% deemed clinically relevant and only 33.5% were clinically useful. Localization reports were completed more frequently before conclusion of surgery (67.2% vs. 34.4%), but with lower clinical relevance (90.1% vs. 98.5%) and clinical usefulness (60.3% vs. 33.6%) than post-instrumentation reports. Each patient was charged $32-$34 for interpretation fee, cumulating a minimum total cost of $15,392. Formal radiographic interpretation of intraoperative spine radiographs was of low clinical utility for spine surgeons. Institutions should consider optimizing radiology workflows to improve timeliness and clinical relevance or evaluate the necessity of reflexive consultation to radiology for intraoperative imaging interpretation to ensure that value-based care is maximized during spine surgeries. 3.

A morphological review of medial malleolar fractures – A large single centre series

BackgroundMany approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. MethodsPatients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records. Retrospective analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. ResultsA total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). Herscovici type A fractures were significantly more frequently mal-reduced at time of surgery as compared to other fracture types (p = .003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who had been anatomically reduced. ConclusionThe morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions. Level of evidenceLevel 3 – Retrospective Cohort Study