Intraoperative Radiographs Research Articles

Registration of MRI to intraoperative radiographs for target localization in spinal interventions

Decision support to assist in target vertebra localization could provide a useful aid to safe and effective spine surgery. Previous solutions have shown 3D–2D registration of preoperative CT to intraoperative radiographs to reliably annotate vertebral labels for assistance during level localization. We present an algorithm (referred to as MR-LevelCheck) to perform 3D–2D registration based on a preoperative MRI to accommodate the increasingly common clinical scenario in which MRI is used instead of CT for preoperative planning.Straightforward adaptation of gradient/intensity-based methods appropriate to CT-to-radiograph registration is confounded by large mismatch and noncorrespondence in image intensity between MRI and radiographs. The proposed method overcomes such challenges with a simple vertebrae segmentation step using vertebra centroids as seed points (automatically defined within existing workflow). Forwards projections are computed using segmented MRI and registered to radiographs via gradient orientation (GO) similarity and the CMA-ES (covariance-matrix-adaptation evolutionary-strategy) optimizer. The method was tested in an IRB-approved study involving 10 patients undergoing cervical, thoracic, or lumbar spine surgery following preoperative MRI.The method successfully registered each preoperative MRI to intraoperative radiographs and maintained desirable properties of robustness against image content mismatch and large capture range. Robust registration performance was achieved with projection distance error (PDE) (median ± IQR) = 4.3 ± 2.6 mm (median ± IQR) and 0% failure rate. Segmentation accuracy for the continuous max-flow method yielded dice coefficient = 88.1 ± 5.2, accuracy = 90.6 ± 5.7, RMSE = 1.8 ± 0.6 mm, and contour affinity ratio (CAR) = 0.82 ± 0.08. Registration performance was found to be robust for segmentation methods exhibiting RMSE <3 mm and CAR >0.50.The MR-LevelCheck method provides a potentially valuable extension to a previously developed decision support tool for spine surgery target localization by extending its utility to preoperative MRI while maintaining characteristics of accuracy and robustness.

A Promising Method for Tumor Localization during Total Laparoscopic Distal Gastrectomy: Preoperative Endoscopic Clipping based on Negative Biopsy and Selective Intraoperative Radiography Findings.

PurposePrecise localization of tumors and creation of sufficient proximal resection margins are complicated processes during total laparoscopic distal gastrectomy (TLDG) for clinical T1/T2 gastric cancers. Various solutions to this problem have also yielded many disadvantages. In this study, we reviewed a preoperative endoscopic clipping method based on the results of negative biopsy and selective intraoperative radiography.Materials and MethodsA retrospective review of 345 consecutive patients who underwent TLDG and preoperative endoscopic clipping for tumor localization was conducted. During preoperative endoscopy, the endoscopists performed negative biopsies just 1–2 cm selectively above the tumor's upper limit. After confirming the biopsy results, endoscopic metal clips were applied just proximal to the negative biopsy site the day before surgery. Selective intraoperative tumor localization using portable abdominal radiography was performed only when we could not ensure a precise resection line.ResultsNegative biopsy was performed in 244 patients. Larger tumor size (P=0.008) and more distally located tumors (P=0.052) were observed more frequently in the negative biopsy group than in the non-negative biopsy group. The non-negative biopsy group had significantly higher frequencies of differentiated tumor types than the negative biopsy group (P=0.003). Of the 244 patients who underwent negative biopsies, 6 had cancer cells in their biopsy specimens. We performed intraoperative radiography in 12 patients whose tumors had difficult-to-determine proximal margins. No tumors were found in the proximal resection margins of any patients.ConclusionsOur tumor localization method is a promising and accurate method for securing a sufficient resection margin during TLDG.

Stress Radiographs under Anesthesia for Painful Chronic Lateral Ankle Instability

Purpose: Anterior drawer and varus stress radiographs are commonly to diagnose chronic lateral ankle instability. We compared the preoperative stress radiographs with the intraoperative radiographs under anesthesia to determine the accuracy and efficacy of stress radiographs in an outpatient clinical environment. Materials and Methods: Data was collected from patients who underwent a modified Broström operation for painful chronic unilateral lateral ankle instability between January 2014 and June 2016. Subjects were divided into three groups—complete tear, partial tear, and instability without rupture—according to the status of preoperative MRI findings of the anterior talofibular ligament. The anterior drawer and varus stress radiographs were taken preoperatively and intraoperatively under anesthesia. Results: Ninety-six patients, with a mean age of 29.63 years, were enrolled. There were 39, 46, and 11 patients in the complete tear, partial tear, and instability without rupture groups, respectively. On the anterior drawer and varus stress radiographs of the affected limb, talar anterior translation and varus tilting were significantly increased by 2.56 mm and 2.0°. The gaps between the unaffected limbs were also increased by 2.47 mm and 1.32° after anesthesia. Although the stress radiographs were taken under anesthesia, the results were often smaller than the diagnostic value. Conclusion: Stress radiographs for painful chronic lateral ankle instability taken at the outpatient clinic might be inaccurate for diagnosis.

Efficacy of decalcified freeze-dried bone allograft in the regeneration of small osseous defect: A comparative study.

Aim:To access the efficacy of decalcified freeze-dried bone allograft (DFDBA) in the regeneration of bone following small osseous defect in minor oral surgery.Objectives:To evaluate the ability of DFDBA to enhance the rate of wound healing and assess radiographic bone density, pain, and infection preoperatively and postoperatively.Materials and Methods:Twenty patients with cysts were assessed. Ten patients were filled with DFDBA (Group 1) and ten without bone graft (Group 2), respectively. Radiographic bone density was assessed on preoperative, intraoperative, and postoperative radiographs on 1st day, 3rd month, and at 6th month using Adobe Photoshop CS6 - Grayscale histogram.Results:Bone density in Group 1 was found to be significantly higher than in Group 2 on 3rd and 6th month postoperatively with a P = 0.024 and P = 0.016 which was statistically significant. The percentage increase in bone density between both the group was determined and yielded no difference over a period of time, but the difference in percentage increase was markedly higher in Group 1 compared to Group 2 at all the time intervals.Conclusion:Bone formed as depicted by bone density is significantly higher when DFDBA is used in small bony defects.

Short Scarf Osteotomy for Hallux Valgus: Short-term and Medium-term Results

ABSTRACT Aim The scarf osteotomy, as popularized by Barouk, is a versatile osteotomy for the correction of moderate and severe hallux valgus deformity. However, this technique requires extensive exposure, fixation, and increased operative time, and is technically demanding. We describe and present our results of a short scarf osteotomy (SSO), which retains all the cuts of a standard scarf but requires a reduced exposure, less metalwork, less operating time, and is more economical. Materials and methods All patients who underwent SSO between January 2010 and December 2012 with minimum follow-up of 12 months were eligible for the study. Preoperative, intraoperative, and postoperative radiographs were available for radiological assessment. Results In this study, 84 patients and 94 feet were included; 90% of patients were satisfied overall, with 83% of patients recommending this surgery to a friend. The hallux valgus angle improved from a preoperative mean of 30.89° (17.4—46.8) to 12° (4—30) postoperatively (p = 0.0001). The intermetatarsal angle improved from a preoperative mean of 15.05° (10.3—21.1) to 7.14° (4—15.1) postoperatively (p = 0.0001). The average sesamoid coverage improved from grade 2.18 (1—3) preoperatively to 0.57 (0—2) postoperatively (p = 0.0001). The average American Orthopedic Foot and Ankle Score improved from 51.26 (32—88) preoperatively to 91.1 (72—100) postoperatively (p = 0.0001). Conclusion We believe that this osteotomy is a novel procedure producing good to excellent results in most cases of hallux valgus. Biologically, the decreased exposure should improve healing and reduce the risk of avascular necrosis. We strongly recommend this osteotomy for most cases of hallux valgus surgery. How to cite this article Dalal R, Rachha R, Leonard D, Chourasia A, Javed S. Short Scarf Osteotomy for Hallux Valgus: Short-term and Medium-term Results. J Foot Ankle Surg (Asia-Pacific) 2017;4(1):14-18.

Subcutaneous Emphysema During Root Canal Therapy: A Case Report

Cervicofacial subcutaneous emphysema is defined as the abnormal introduction of air in the subcutaneous tissues of the head and neck. It is mainly caused by trauma, head and neck surgery, general anesthesia, and coughing or habitual performance of Valsalva manoeuvre. The occurrence of subcutaneous emphysema after dental treatment is rare, and diffusion of gas into the mediastinum is much rarer, especially when the procedure is a nonsurgical treatment. Presented here is a case of subcutaneous emphysema that occurred after sodium hypochlorite irrigation during endodontic treatment, and the description of its etiologies and prevention during nonsurgical endodontic treatment. Endodontic success can be essentially achieved via good debridement of a root canal, and an ideal endodontic irrigant is effective in removing the smear layer, opening the dentinal tubules, and producing a clean surface for closer obturation. A 60-years-old woman had an abnormal swelling and pain during an endodontic treatment accompanied by her dentist to the emergency room and was referred to our observation for complaining of severe pain, ecchymosis and severe swelling on the left side of her face. The aforementioned symptoms appeared after sodium hypochlorite irrigation and aggressive use of air spray for drying the root canal during the endodontic treatment of the upper left lateral incisor. An extrusion during an inappropriate endodontic treatment may occasionally be reported and can cause tissue damage. NaOCl is one of the best and most commonly used irrigating solutions because of its efficacy, but it can also negatively affect the periapical tissues. Determining the correct working length, even when performing an intraoperative periapical radiograph and confirming the root canal integrity, could help avoid these kinds of accidents.

What Is Important for Confirming Negative Margins When Resecting Mandibular Ameloblastomas?

The purpose of this study was to assess the utility of intraoperative radiographs and frozen sections in achieving negative margins and preventing recurrence of mandibular ameloblastomas. This was a retrospective cohort study of patients who underwent resection (≥1cm) of mandibular ameloblastomas from 2005 through 2015. Patients were included if they had at least 1-year follow-up and complete records. Demographic variables included age, gender, and type of resection (segmental vs marginal). Predictor variables were type of margin assessment: 1) frozen section, 2) intraoperative exvivo specimen radiograph, 3) both, or 4) none. The outcome variables were final margin status and recurrence rate. Accuracy of intraoperative radiographic margins was determined by comparison with histologic margin distance. Descriptive statistics were conducted with the Fisher exact test. The study sample consisted of 35 patients (47.5 ± 20.4yr old; 16 men) who underwent 25 segmental and 10 marginal resections. Ten had frozen sections only, 3 had exvivo specimen radiographs only, 10 had no intraoperative measurements, and 12 had both. There were no positive frozen sections. One patient had a positive posterior bony margin at final pathology despite negative frozen section histology. There was no difference in recurrence rate at latest follow-up among cohorts. The anterior radiographic margin was 11.8 ± 5.9mm compared with 11.5 ± 7.5mm by histology (P= .124). Theposterior radiographic margin was 12.3 ± 5.3mm compared with 9.8 ± 6.5mm histologically (P=.546). Margin distances that were at least 5mm when measured with specimen radiographs had histologic margin distances of at least 5mm in 25 of 30 resection margins (83.3%). Resection of ameloblastoma with planned margins of at least 1cm is sufficient to prevent recurrence of ameloblastoma. Achieving a radiographic margin of at least 5mm provided a histologic margin of at least 5mm 83.3% of the time.

PMD115 - The Situate Detection System - A Cost-Effective Approach to Preventing Retained Surgical Sponges

Estimate the cost-effectiveness of utilizing the SituateTM radiofrequency (RF) Detection System plus manual tracking of surgical sponges versus manual tracking alone, to prevent the incidence of retained surgical sponges (RSS). We developed a one-year decision analytic model to assess the clinical and economic impacts of utilizing SituateTM Detection System to prevent RSS in a surgical facility performing 10,000 surgeries annually, using inputs from literature and clinical expert opinion. We estimated the incremental costs per RSS avoided by modeling the following parameters: counting discrepancy rates; diagnostic performance of SituateTM Detection System, manual counting, and intraoperative radiographs; time associated with searching inside/outside the surgical field and waiting for/reading radiographs; and cost of operating room (OR) time, radiographs, RF-tagged sponges and SituateTM Detection System wand covers, and infections, unreimbursed procedure, and legal costs associated with RSS. Model parameters were varied through one-way sensitivity and scenario analyses to test the robustness of model results. Under base case assumptions, SituateTM Detection System dominated manual counting alone by preventing 2 additional RSS while resulting in $620,789 fewer costs. Cost reductions were due to the efficiencies gained by using the device, lower utilization of radiographs, and fewer medical/legal costs resulting from RSS. Model results were robust to the sensitivity analyses. Even with legal costs removed from the model, which was by far the greatest cost, to conservatively reflect an ex-U.S. medical malpractice landscape, SituateTM Detection System still reduced costs by $65,448 and continued to dominate manual counting. The implications of RSS can be both clinically and economically significant for patients and healthcare facilities, and the literature suggests that standard manual counting is not optimal in preventing RSS. Our model suggests that, even using conservative estimates, SituateTM Detection System can avert medical and legal costs, decrease unproductive OR time, and most importantly, more effectively prevent RSS.

Routine radiographs one day after anterior cervical discectomy and fusion are neither necessary nor cost-effective

Objectives: Anterior cervical discectomy and fusion (ACDF) is a common operative treatment of compressive pathology of the cervical spinal cord, when caused by one or more degenerated intervertebral discs or related osteophytes. In addition to intra-operative radiographs to confirm spinal level before discectomy and implant position after insertion, traditional practice is to obtain post-operative antero–posterior and lateral plain radiographs (XR) before hospital discharge, despite a paucity of evidence supporting their benefit to patient care. Minimising unnecessary radiation to radiosensitive neck structures is desirable, and furthermore, with increasing financial pressure on healthcare resources, routine investigations should be clinically justified and evidence-based. We aim to compare the utility of routine post-operative cervical spine X-rays following ACDF.Methods: We compare two groups of consecutive patients undergoing ACDF in a single UK neurosurgical centre. The first group (n = 109) received routine post-operative XR imaging, and the second group (n = 113) received radiographs only when clinically indicated.Results: There were no differences in post-operative complication rates (4.6% vs. 5.3%), or requirement for further imaging or of further operative intervention (1.8% vs. 0.9%). The group that did not have routine post-operative radiographs had a significantly shorter stay in hospital (median two days vs. three days). There were no patients in either group where post-operative XR changed clinical management and mandated revision surgery or further imaging. All cases requiring surgery or further imaging were identified by clinical deterioration.Conclusions: We suggest that the practice of obtaining routine radiographs of the cervical spine following ACDF should be abandoned, unless there is a clear clinical indication.

Operative Fixation of Chronic Acromioclavicular Joint Dislocation With Hook Plate and Modified Ligament Transfer.

The optimal treatment for acute dislocation of the acromioclavicular (AC) joint remains unclear, and prior randomized trials did not reveal any significant improvements in the operative groups. However, it is clear that some patients treated nonoperatively are dissatisfied with their outcome and request surgical correction. This video demonstrates one method of repair of a chronic dislocation of the AC joint in a patient with significant symptomatology following nonoperative treatment of a high-grade AC dislocation. This video demonstrates the open reduction of a chronically dislocated AC joint. After mobilization of the distal clavicle and debridement of the joint, a step cut is made in the anterior surface of the distal clavicle. The coracoacromial (CA) ligament is then identified and mobilized, taking care to preserve its acromial origin. An anterior acromioplasty is then performed with a microsaggital saw. The AC joint is reduced, and the acromial fragment is sculpted to fit the step cut in the distal clavicle, where it is then fixed with a small-fragment cancellous screw in lag fashion. The blade of the hook plate is then contoured to fit under the acromion (posteriorly) to hold the joint in a reduced position. The deltoid is repaired with number 1 absorbable sutures, followed by a standard closure. Results are improved and complications minimized when care is taken to not avoid overreduction of the clavicle: an intraoperative radiograph, and/or comparison to the opposite side, may be useful. We do not shorten or resect the entire distal clavicle: this has been shown to lead to worse outcomes. We have found that CA transfer with a fragment of attached acromial bone results in more reliable healing than a CA transfer alone (the Weaver-Dunn transfer). In the setting of a chronic AC dislocation, hook plate fixation provides excellent reduction of the joint and a stable mechanical environment: this allows for the optimal healing of the ligament transfer. Typically, 6-12 months postoperatively, the hook plate can be removed to improve motion and reduce local irritation because joint stability is then provided by the transfer with bone-to-bone healing.

An Alternative Intraoperative Radiographic Method for Optimizing Cup Inclination during Total Hip Arthroplasty.

During total hip arthroplasty (THA), the location of the acetabular prosthesis is very important for guaranteeing successful surgery. However, this remains a challenge for many surgeons. This study aimed to investigate the feasibility of using the intraoperative fluoroscopic iliopubic tangential angle (IPTA) to determine the valgus angles of acetabular prostheses. In the first stage, the IPTA and valgus angles of native acetabula were defined and measured in 102 THAs obtained from the picture archiving and communication systems of our hospital. Obturator foramen morphology was also measured and divided into groups according to the axial length ratio. Correlations between obturator foramen morphology and IPTA and valgus angles of native acetabula were then determined. In the second stage, angular differences (angle θ) between the IPTA and valgus angles of native acetabula were measured during unilateral THA in 136 patients to determine whether this is a stable value that could be used as a reference for placement of acetabular prostheses. Postoperative data such as Harris Hip Score (HHS) scores and complications were collected and evaluated. The average IPTA at the apex of the true acetabulum was 58.8° ± 4.1°. The average valgus angle of native acetabula was 43.1° ± 3.9° and angle θ was 15.7° ± 1.3°. Obturator foramen morphology was divided into five groups according to the axial length ratio. IPTA was closely related to obturator foramen morphology (Pearson r = 0.489, P ≈ 0.000). Angle θ was stable and independent of obturator foramen morphology. When the IPTA and angle θ were used as references for placing acetabular prostheses in 136 THAs, the average postoperative valgus angles of acetabular prostheses was 45.13° ± 4.07° and the good-to-excellent rate was 97.05%. There were no short-term complications such as fracture, dislocation or infection. The average HHS score 6 months after surgery was 37.2 higher than the preoperative score, this difference being significant (P < 0.01). Neither infection nor dislocation was found 6 months after surgery. The IPTA (at the apex of the true acetabulum) and angle θ (obtained by intraoperative fluoroscopy) are consistent in determining the postoperative valgus angle of acetabular prosthesis during THA. Thus, IPTA and angle θ are of value in guiding placement of acetabular prostheses; in particular, this method can facilitate the learning of young surgeons.

Intraoperative fluoroscopic assessment of proper prosthetic radial head height

Selecting a properly sized radial head prosthesis is imperative during radial head replacement. Although there has been much emphasis on avoiding overlengthening of the radius, little has been studied about how to avoid shortening. The purpose of this study was to characterize how a radial head replacement appears on intraoperative fluoroscopy depending on the height of the prosthetic radial head. Articular cartilage thickness of the radial head was measured in 9 cadaveric elbows. Radial head replacement was performed in each specimen with 4 different prosthetic head heights: 4 mm and 2 mm shortening, anatomic, and 2 mm overlengthening. Anteroposterior fluoroscopic images were obtained for each head height, and the prosthetic radial head height was measured at 3 forearm positions (supination, neutral, and pronation) using the subchondral bone of the lateral edge of the coronoid at the reference point. The mean cartilage thickness of the radial head was 1.3 ± 0.4 mm. The prosthetic radial head appeared 2.2 ± 0.4 mm more proximal than the subchondral bone of the coronoid lateral edge in anteroposterior radiographs when the articular surface of the prosthesis was completely even with the coronoid articular surface. Unlike the native radial head, a prosthetic radial head showed a significant change of height with different forearm rotation (P < .001). This study found that a perfectly anatomic radial head replacement appears overlengthened by approximately 2 mm in intraoperative radiographs. This finding can be useful in guiding the appropriate height of a prosthetic radial head.

WE‐AB‐BRA‐09: Registration of Preoperative MRI to Intraoperative Radiographs for Automatic Vertebral Target Localization

Purpose:Accurate localization of target vertebrae is essential to safe, effective spine surgery, but wrong‐level surgery occurs with surprisingly high frequency. Recent research yielded the “LevelCheck” method for 3D‐2D registration of preoperative CT to intraoperative radiographs, providing decision support for level localization. We report a new method (MR‐LevelCheck) to perform 3D‐2D registration based on preoperative MRI, presenting a solution for the increasingly common scenario in which MRI (not CT) is used for preoperative planning.Methods:Direct extension of LevelCheck is confounded by large mismatch in image intensity between MRI and radiographs. The proposed method overcomes such challenges with a simple vertebrae segmentation. Using seed points at centroids, vertebrae are segmented using continuous max‐flow method and dilated by 1.8 mm to include surrounding cortical bone (inconspicuous in T2w‐MRI). MRI projections are computed (analogous to DRR) using segmentation and registered to intraoperative radiographs. The method was tested in a retrospective IRB‐approved study involving 11 patients undergoing cervical, thoracic, or lumbar spine surgery following preoperative MRI. Registration accuracy was evaluated in terms of projection‐distance‐error (PDE) between the true and estimated location of vertebrae in each radiograph.Results:The method successfully registered each preoperative MRI to intraoperative radiographs and maintained desirable properties of robustness against image content mismatch, and large capture range. Segmentation achieved Dice coefficient = 89.2 ± 2.3 and mean‐absolute‐distance (MAD) = 1.5 ± 0.3 mm. Registration demonstrated robust performance under realistic patient variations, with PDE = 4.0 ± 1.9 mm (median ± iqr) and converged with run‐time = 23.3 ± 1.7 s.Conclusion:The MR‐LevelCheck algorithm provides an important extension to a previously validated decision support tool in spine surgery by extending its utility to preoperative MRI. With initial studies demonstrating PDE &lt;5 mm and 0% failure rate, the method is now in translation to larger scale prospective clinical studies.S. Vogt and G. Kleinszig are employees of Siemens Healthcare

WE‐AB‐BRA‐07: Operating Room Quality Assurance (ORQA) for Spine Surgery Using Known‐Component 3D‐2D Image Registration

Purpose:Intraoperative x‐ray radiography/fluoroscopy is commonly used to qualitatively assess delivery of surgical devices (e.g., spine pedicle screws) but can fail to reliably detect suboptimal placement (e.g., breach of adjacent critical structures). We present a method wherein prior knowledge of the patient and surgical components is leveraged to match preoperative CT and intraoperative radiographs for quantitative assessment of 3D pose. The method presents a new means of operating room quantitative quality assurance (ORQA) that could improve quality and safety, and reduce the frequency of revision surgeries.Methods:The algorithm (known‐component registration, KC‐Reg) uses patient‐specific preoperative CT and parametrically defined surgical component models within a robust 3D‐2D registration method to iteratively optimize gradient similarity using the covariance matrix adaptation evolution strategy. Advances from previous work address key challenges to clinical translation: i) absolving the need for offline geometric calibration of the C‐arm; and ii) solving multiple component bodies simultaneously, thereby allowing QA in a single step (e.g., spinal construct with 4–20 screws), rather than sequential QA of each component. Performance was tested in a spine phantom with 10 pedicle screws, and first results from clinical studies are reported.Results:Phantom experiments demonstrated median target registration error (TRE) of (1.0±0.3) mm at the screw tip and (0.7°±0.4°) in angulation. The simultaneous multi‐body registration approach improved TRE from the previous (sequential) method by 42%, reduced outliers, and fits into the natural workflow. Initial application of KC‐Reg in clinical data shows TRE of (2.5±4.5) mm and (4.7°±0.5°).Conclusion:The KC‐Reg algorithm offers a potentially valuable method for quantitative QA of the surgical product, using radiographic systems that are already within the surgical arsenal. For spine surgery, the method offers a near‐real‐time independent check on the quality of surgical product, facilitating immediate revision if necessary and potentially avoiding postoperative morbidity and/or revision surgery.Gerhard Kleinszig and Sebastian Vogt are employees of Siemens Healthcare.

Validity and Reliability of Intraoperative Radiographs to Assess Leg Length During Total Hip Arthroplasty: Correlation and Reproducibility of Anatomic Distances

BackgroundLeg length discrepancy after total hip arthroplasty is a frequent complication. The aim of this study was to assess the validity (correlation) and reproducibility (inter-rater agreement) of various intraoperative hip radiographs measures to estimate leg length. MethodsPatients were included if they were aged 15 years or older; were eligible for a total hip arthroplasty, and were operated in lateral recumbent. An intraoperative hip radiograph was performed with the definitive implants in place. At 6 weeks postoperatively, anteroposterior pelvis radiograph was taken. We used 3 measures to assess leg length: the height from the ischial tuberosity to the lesser trochanter (LTI), the height from the center of femoral head to the greater trochanter (GTC), and to the inferior teardrop (TC). ResultsThe study group consisted of 71 hips with an average age of 69 years (range, 24-92 years). The correlation was 0.545 (95% CI: 0.35-0.69) for GTC, 0.75 (95% CI: 0.61-0.84) for TC, and 0.70 (95% CI: 0.56-0.80) for LTI. Intraoperative and postoperative measures were statistically different for GTC (<0.0001) and TC (<0.0001), and not significant for LTI (P = .06). Reproducibility of these measures were excellent with intraclass correlation coefficients of 0.977, 0.814, and 0.983 for the GTC, TC, and LTI, respectively. ConclusionNone of the parameters used to assess leg-length based on an intraoperative radiograph showed good correlation with the postoperative radiograph.

Utility of the LevelCheck Algorithm for Decision Support in Vertebral Localization.

An automatic radiographic labeling algorithm called "LevelCheck" was analyzed as a means of decision support for target localization in spine surgery. The potential clinical utility and scenarios in which LevelCheck is likely to be the most beneficial were assessed in a retrospective clinical data set (398 cases) in terms of expert consensus from a multi-reader study (three spine surgeons). The aim of this study was to evaluate the potential utility of the LevelCheck algorithm for vertebrae localization. Three hundred ninety-eight intraoperative radiographs and 178 preoperative computed tomographic (CT) images for patients undergoing spine surgery in cervical, thoracic, lumbar regions. Vertebral labels annotated in preoperative CT image were overlaid on intraoperative radiographs via 3D-2D registration. Three spine surgeons assessed the radiographs and LevelCheck labeling according to a questionnaire evaluating performance, utility, and suitability to surgical workflow. Geometric accuracy and registration run time were measured for each case. LevelCheck was judged to be helpful in 42.2% of the cases (168/398), to improve confidence in 30.6% of the cases (122/398), and in no case diminished performance (0/398), supporting its potential as an independent check and assistant to decision support in spine surgery. The clinical contexts for which the method was judged most likely to be beneficial included the following scenarios: images with a lack of conspicuous anatomical landmarks; level counting across long spine segments; vertebrae obscured by other anatomy (e.g., shoulders); poor radiographic image quality; and anatomical variations/abnormalities. The method demonstrated 100% geometric accuracy (i.e., overlaid labels within the correct vertebral level in all cases) and did not introduce ambiguity in image interpretation. LevelCheck is a potentially useful means of decision support in vertebral level localization in spine surgery. N/A.

Fracture Care Challenges in the Austere and Humanitarian Environments

It is estimated that 80 % of severe fractures occur in the developing world. Long bone fractures of the femur and tibia treated conservatively with traction and casts require prolonged hospital stays and still often leave patients with significant lifelong disability. Locked intramedullary nailing is the standard of care in the developed world for management of these fractures. Humanitarian fracture care in an austere environment often means limited or no access to implants, a reliable power supply and intraoperative radiography traditionally required for locked intramedullary nailing. Creative surgeons with extensive experience in humanitarian work are making significant contributions to improve the management of these complex fractures in the austere environment through education of local surgeons and innovations in orthopedic implants and instrumentation.

Limited open reduction with internal fixation versus closed reduction with external fixation in the treatment of irreducible supracondylar humerus fractures in children: an outcome comparison

Objective To compare the clinical results of treating irreducible supracondylar humerus fractures (Gartland type Ⅲ) in children with limited open reduction and internal fixation versus closed reduction with external fixator. Methods The clinical data of 34 pediatric patients who had been treated for supracondylar humerus fractures (Gartland type Ⅲ) from January 2012 to January 2014 were available for retrospective analysis. Eighteen patients were treated with limited open reduction via a limited medial or lateral incision followed by percutaneous Kirschner wire fixation (internal fixation group). The other 16 patients were treated with closed reduction followed by application of an external fixator (external fixation group). Surgery time, intraoperative radiography frequency, fracture healing time, the change of Baumann angle at 3 days and 2 months postoperatively, and elbow function were compared between the two groups. Results All the patients received a mean follow-up of 16.5 months (range, 12 to 24 months). Compared with the external fixation group, the internal fixation group needed significantly shorter average surgery time (49.1±6.6) minutes versus (72.3±12.6) minutes and significantly lower average intraoperative radiography frequency (3.6±0.9) times versus (10.1±2.0) times (P<0.05). All the fractures achieved clinical healing at 4 weeks postoperatively and bone union at 2 months postoperatively. The change of Baumann angle between 3 days and 2 months postoperatively was (2.4±1.3)° on average in the internal fixation group and (6.1±2.1)° on average in the external fixation group, with a significant difference (P<0.0001). Evaluation of elbow function using the Flynn elbow scoring system at 3 months postoperatively revealed a 27.8% (5/18) good to excellent rate in the internal fixation group and 25.0% (4/16) in the external fixation group. The good to excellent rate increased to 99.4% (17/18) in the internal fixation group and to 81.3% (13/16) in the external fixation group at 12 months postoperatively. There were no complications such as delayed union, compartment syndrome or iatrogenic lesions to vessels and nerves. Conclusion In the treatment of pediatric irreducible supracondylar humeral fractures (Gartland type Ⅲ), both limited open reduction with internal fixation and closed reduction with external fixation can lead to fracture healing within similar time. Limited open reduction with internal fixation can achieve more satisfactory reduction and more stable fixation, and can result in shorter operative time, lower intraoperative radiography frequency and better elbow function. Key words: Child; Fracture fixation, internal; External fixators; Supracondylar humerus fracture

A Radiological Evaluation of Effect of a Single Level Trans-Foraminal Lumbar Interbody Fusion (TLIF) on Lumbar Sagittal Parameters

Aim To investigate the effect of a primary single level TLIF on the lumbar sagittal profile (segmental lordosis and total lumbar lordosis) comparing pre-operative, intra-operative and post-operative radiographs in patients with lumbar spine degenerative disease. Methods Patients over the age of 16 who underwent a single-level interbody fusion for degenerative stenosis and/or spondylolisthesis without scoliosis between March 2008 and March 2014 were reviewed. Age, gender, surgical level, surgical approach, facetectomy (unilateral vs bilateral) were recorded. Standardized pre and early and 6 month postoperative upright radiographs as well as an intra-operative lateral radiographs were analyzed for the pelvic incidence (PI), segmental lordosis (SL) at the TILF level and total lumbar lordosis (TL). Data analysis was performed after confirming normality using a paired t-test and is presented as mean (SD). p-value &lt; 0.05 was considered significant. Results 69 patients were reviewed. The mean age was 58.6 (13.6) years, 39 males (56.5%), a Wiltse approach was used in 30 (43.5%) while 39 had a midline posterior approach. Segments operated were L2/L3 (1 case), L3/L4 (6), L4/L5 (43), L5/S1 (19) and bilateral facetectomy was performed in 13 (18.8%). SL changed from 15.2° (7.3) preoperatively to 20.4° (7.7) intraoperatively ( p-value &lt; 0.0001) but measured 17.9° (7.2) ( p-value &lt; 0.0001) on early postoperative images and 17.2° (7.3) at 6 months follow up ( p-value= 024). The total improvement in SL at 6 months was 2° (6.7), ( p-value= 0.001). TL change was insignificant on the early postoperative X-rays (48.5° (12.4) to 47.2° (11.3), p-value= 0.37) but significantly increased to 53.1° (11.5) at six months ( p-value &lt; 0.0001) with a total improvement of 4.6° (10) ( p-value= 0.001). The mean pelvic incidence was 59.7° (11.2). The cage subsided in 11 (15.9%) cases and we had no metal work loosening. Conclusion At the level of the TLIF, much of the lordosis achieved intra-operatively is lost once the patient mobilizes. An improvement in the total lumbar lordosis at 6 months following surgery is likely to be due to the decompression component of the surgical intervention.

Arthroscopically Assisted Open Reduction–Internal Fixation of Ankle Fractures: Significance of the Arthroscopic Ankle Drive-through Sign

Standalone open reduction–internal fixation (ORIF) of unstable ankle fractures is the current standard of care. Intraoperative stress radiographs are useful for assessing the extent of ligamentous disruption, but arthroscopic visualization has been shown to be more accurate. Concomitant arthroscopy at the time of ankle fracture ORIF is useful for accurately diagnosing and managing syndesmotic and deltoid ligament injuries. The arthroscopic ankle drive-through sign is characterized by the ability to pass a 2.9-mm shaver (Smith & Nephew, Andover, MA) easily through the medial ankle gutter during arthroscopy, which is not usually possible with both an intact deltoid ligament and syndesmosis. This arthroscopic maneuver indicates instability after ankle reduction and fixation and is predictive of the need for further stabilization. Furthermore, when this sign remains positive after fracture fixation, it may guide the surgeon to further evaluate the adequacy of fixation for the possible need for further fixation of the syndesmosis or deltoid. We present the case of an ankle fracture managed with arthroscopy-assisted ORIF and describe the clinical utility of the arthroscopic ankle drive-through sign.