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Introduction Cage migration into the retroperitoneal space during posterior lumbar interbody fusion rarely occurs. Here, we report a patient who underwent laparoscopic surgery to remove a migrated cage from the retroperitoneal space. Case Presentation A 76-year-old woman had a cage that had migrated into the retroperitoneal space during posterior lumbar interbody fusion. On abdominal CT, the migrated cage appeared at the front of the promontorium, just below the aortic and vena caval bifurcations. One day later, the patient underwent laparoscopic surgery using intraoperative fluoroscopy to extract the migrated cage. The patient's postoperative course was uneventful, and she was discharged on the fifth postoperative day. Discussion A cage that migrates during posterior lumbar interbody fusion can have serious consequences. In cases where the patient remains in stable condition, laparoscopic surgery is a useful and suitable method for removing the cage from the retroperitoneal space.

This study was carried out to evaluate the benefits of personalized three-dimensional printing as an aid to the performance of surgery for the correction of spinal deformity in children with myelomeningocele. We performed a retrospective review to include all such children for whom personalized three-dimensional spine models were used for surgical planning (group A) and compared them through subjective and objective criteria to a similar group that had no models (group B). The seven children in group A were younger and had more complex deformities than the 10 children in group B. The models provided a markedly improved appreciation of the complex anatomy and enabled the planning and performance of patient-specific spinal instrumentation that was secure and low profile. The efficiency of the surgery as measured by intraoperative fluoroscopy time and blood loss and the extent of the deformity correction was comparable or superior in group A.

Summary The aim of this study was to present the results of one original method application in internal fixation of long bones. The series of 27 patients with unilateral fractures of femoral shaft was analyzed. According to AO classification, 21 fractures were classified as 32A, five as 32B, and one as 32C type. Original diaphyseal self-dynamisable internal fixator (model 1) was used as a fixation implant, consisting of three components: specially designed extramedullary bar, clamps and screws. The main feature of this implant is a possibility to become dynamic in the axial direction spontaneously if there is no sufficient fracture healing. Because of that, this implant is known as an „intelligent implant“. Surgical method included a standard surgical approach and minimally invasive surgical approach. Minimally invasive technique of application required less blood transfusion and shorter surgery time when compared to the standard surgical approach. The duration of used intraoperative fluoroscopy control was 7(3-18) seconds. The average healing time was 4.3 (3.5-9.5) months. There were neither intra operative nor postoperative complications. In comparison to intramedullary nails, self-dynamisable internal fixator provides a similar treatment results, while in comparison to plates it provides fewer mechanical complications. Self-dynamisable internal fixator method preserves periosteal and intramedullary blood circulation, and it is the first fixation implant with a possibility of spontaneous axial dynamising activation when needed. This implant has been proven as suitable for routine use in the treatment of femoral shaft fractures.

In the field of spinal surgery, 3D-fluoroscopy navigation-assisted pedicle screw (PS) insertion with intra-operative 3D-image control represents a modern application of contemporary navigation technology. In literature, sectional or vertebral accuracy limitations of this image-guidance approach are not profoundly specified. This observational study explicitly differentiates accuracy rates and misplacement mode between spinal sections and single vertebrae from T10 to S1 using a navigation-assisted approach. From February 2011 through July 2015, all 3D-fluoroscopy navigation-assisted, 3D-image controlled PS insertions from T10 to S1 were prospectively recorded and evaluated for PS insertion depth, angulation, and entering-point modifications after intraoperative O-arm control scanning. Major complications requiring revision surgery for neurological damage/major bleedings, and procedure-related unintended violations of anatomical structures were recorded. In 1547 navigation-assisted PS insertions, thoracolumbar accuracy (96.4%) was significantly higher than sacral accuracy (92.6%, p ≈ 0.007) due to special requirements to exact PS (insertion depth) in S1 (p

A 60-year old woman had been hospitalized in a psychiatric hospital for 40 years for schizophrenia. An X-ray was performed when she fell, which showed needles in the abdominal field. After additional examinations and questioning, the patient was diagnosed with needles in the abdominal cavity, which were assumed to have been ingested and to have perforated the GI tract 40 years ago. They were removed by laparoscopic surgery. The needles were found in the omentum and near the left ovary. There were no inflammatory reactions around them. There have been previous reports about the removal of intra-abdominal foreign bodies, but foreign body reaction occurred in most of the reports. Our case had the longest period from ingestion of the foreign bodies to their removal. Laparoscopy and intraoperative fluoroscopy are useful for removing intra-abdominal foreign bodies because of their ability to help discriminate between structures and to navigate in real time.

Transcondylar screw fixation was performed using a minimally invasive percutaneous technique on three dogs (four elbows) diagnosed with incomplete ossification of the humeral condyle. The technique was performed using an aiming device in all four elbow joints and assisted by intraoperative fluoroscopy in one. All screws were successfully placed on first attempt and no elbow joint required repositioning of the transcondylar screw. On immediate postoperative radiographs, median transcondylar screw angulation was 2.9° and median percentage of screw eccentricity relative to the theoretical center of the humeral condyle was 14%. No short-term postoperative complications (

Background. PICCs are venous access systems designed for medium operation duration. Simple installation and a minimum percentage of complications allow using them in the treatment of children with cancer as an alternative to subclavian catheters, the most common in the medical institutions of the Russian Federation. Methods . The analysis included 353 patients (3 months up to 17 years, mean age 11.2 years) with a variety of cancer diseases who were catheterized with 354 PICCs in 2011–2016. All settings are carried out using ultrasound navigation. External anatomical landmarks were used in 138 (39%) patients to perform PICCs, intraoperative fluoroscopy – in 216 (61%) patients. Results . Maximum operation duration was 1.3 years, the lowest — 1.5 months, average — 6.3 months. The most common technical difficulty during installation we have faced with was the migration of the distal end of the catheter into the internal jugular vein against blood flow registered in 32 (9%) patients. In 1 (0.3%) case, we were unable to catheterize the patient's vein. One of the most common complications of operation was PICCs thrombosis registered in 26 (7.3%) cases. Venous thrombosis was observed in 16 (4.5%) cases. Catheter-related bloodstream infections were not reported. Removal of PICCs related to the complications were performed in 30 (8,5%) patients who were later implanted venous ports. Conclusion . PICCs are recommended for application in the treatment of children with cancer. The nursing staff should be trained to minimize the risk of complications.

Intraoperative fluoroscopy can improve the precision of acetabular component positioning during direct anterior hip arthroplasty. However, changes in pelvic tilt with c-arm positioning may compromise accuracy. A geometric model of an acetabular component's projection onto fluoroscopy images was created and manipulated to simulate c-arm tilt. An apparently ideally-placed cup will have its effective anteversion changed by 7.5° with just 10° of caudal/cephalad tilt of the c-arm. This effect is greater in cups that are more horizontally placed or less anteverted. Accurate c-arm positioning is crucial, as small errors in tilt can have considerable effects on final cup position.

Background: Robotic-guided navigation systems for pedicle screw placement has gained recent interest to ensure accuracy and safety and diminish radiation exposure. There have been no published studies using a new combined robotics and navigation system (Globus ExcelsiusGPS system). The purpose of this study was to demonstrate safety with this system. Methods: This is a case series of consecutive patients at a single institution from February 1, 2018, to August 31, 2018. All patients who had planned placement of thoracic and lumbar pedicle screws using the combined robotics-navigation system were included. Chart review was performed for operative details. A subgroup analysis was performed on patients with postoperative computed tomography (CT) scans to assess screw placement accuracy using the Gertzbein and Robbins system. Acceptable pedicle screw position was defined as grade A or B. Results: One hundred six patients were included, with 636 pedicle screws, 6 iliac screws, and 1 S2AI screw. Five cases were aborted for technical issues. In the remaining 101 patients, 88 patients had screws placed using preoperative CT planning and 13 patients using intraoperative fluoroscopy planning. All screws except for 5 pedicle screws in 2 patients were placed successfully using the robot (99%). These 5 pedicle screws were placed by converting to a fluoro-guided technique without robotic assistance. Eighty-six patients had screws placed using a percutaneous technique, and 15 patients had screws placed using an open technique. Ninety-eight patients underwent interbody placement: 28 anterior lumbar interbody fusions (ALIFs), 12 lateral lumbar interbody fusions (LLIFs), and 58 transforaminal lumbar interbody fusions (TLIFs). All ALIFs and LLIFs were performed prior to placement of the screws. Four LIF patients had screws placed in the lateral position. No patients had screw-related complications intraoperatively or postoperatively, and no patients returned to the operating room for screw revision. Thirteen patients underwent postoperative CT for various reasons. Of the 66 pedicle screws that were examined with postoperative CT, all screws (100%) had acceptable position. Conclusion: This study demonstrates that the combined robotics and navigation system is a novel technology that can be utilized to place pedicle screws and pelvic screws safely and has the potential to reduce screw-related complications. Level of Evidence: 4 (case series).

Minimally invasive fracture repair (MIFR) is the ultimate culmination of current osteosynthesis concepts that emphasize the preservation and enhancement of the biologic components of fracture healing. Although the "less is more" approach to tissue dissection and fracture exposure and handling that defines MIFR has numerous reported advantages over more traditional open surgical treatments, it does present some unique challenges and important considerations for the surgeon. This article describes some of the general MIFR challenges a surgeon may encounter.

Few intraoperative assessments are available for hindfoot alignment. In the current study, we demonstrated the feasibility of hindfoot alignment via intraoperative fluoroscopy. We retrospectively compared measurements of heel alignment obtained via intraoperative fluoroscopy with those acquired using standard radiographs. Two observers compared the heel alignment ratios and angles derived from 100 pairs of images. The effects of age, sex, laterality, and body mass index on the discrepancy between fluoroscopic images and radiographs were analyzed. The heel alignment ratio revealed a strong correlation between standing radiograph and intraoperative fluoroscopy, based on a correlation coefficient of 0.844 (p.001). The heel alignment angle also showed significant correlation based on a correlation coefficient value of 0.667 (p.001). None of the demographic factors showed any significant effect on the discrepancy between the 2 sets of images. Our study showed that the heel alignment determined via intraoperative fluoroscopy was comparable to that of a standard standing radiograph without any significant association with demographic factors.

Introduction and Objectives: Fluoroscopy units are routinely operated in the automatic brightness control (ABC) mode to optimize image quality. During ureteroscopy, objects may be placed w...

Objective To quantify the relationship between the electrical power requirement to achieve pain relief and the position of the active electrode of dorsal root ganglion stimulators within the spinal nerve root exit foramen. Materials and Methods Retrospective analysis of prospectively collected data of 92 consecutive patients undergoing dorsal root ganglion stimulation (DRGS) for chronic pain in a single center. Cervical and sacral cases, and failed trials/explanted DRGS were excluded, so we report on 57 patients with 78 implanted leads. Anteroposterior and lateral fluoroscopic images of the lead in the exit foramen were examined, and the active electrode positions were put into categories depending on their location relative to fixed anatomical landmarks. The clinical outcome and the power requirements for each of these groups of electrodes were then analyzed. Overall pain outcome was assessed by numeric pain rating scale score pre‐operatively and post‐operatively. Results There was no significant relationship between power requirements and mediolateral electrode position, although the lowest average was observed with electrode positions directly below the center of the pedicle. On lateral x‐ray, the lowest power requirements were observed in the electrodes positioned superodorsally or dorsally within the foramen. Importantly, power requirements in this location were consistently low, while the power requirements in other locations were not only higher but also much more variable. Electrodes in the superodorsal position required a median output power almost four times lower than electrodes in other positions (p = 0.002). Clinical outcome was not significantly related to power requirement or foraminal position. Conclusion Aiming for a superodorsal electrode position on lateral intraoperative fluoroscopy is desirable, since siting leads in this location reduces the required stimulator output power very substantially and thus will extend battery life. Position within the foramen does not determine clinical outcome, and so the implanter can safely aim for the low power site without detriment to the analgesic efficacy of the system.

This surgical video is the first to demonstrate a novel minimally invasive technique of utilization of surgically navigated foraminal discectomy using a 3-dimensional 4k high-definition exoscope (Sony Olympus). Typical approaches for foraminal disc herniations may involve violation of the facet resulting in subsequent destabilization requiring fusion.1 Although minimally invasive facet-sparing contralateral techniques have previously been described,2 there is continued limitations stemming from rudimentary localization with standard fluoroscopy and impaired visualization with the bulky traditional operative microscope.3 We demonstrate that high-quality real-time navigation is possible using standard Iso-C intraoperative fluoroscopy for 3-dimensional reconstructions, allowing for intraoperative routing. Navigation is particularly advantageous for adjustments in the trajectory of the tubular retractor and for confirmation of complete foraminal decompression. Visualization from the 4k high-definition exoscope also allows for an unparalleled view of the narrow operative corridor and allows for participation from the operative team. Informed consent was obtained from the patient for the surgery in its entirety.

We describe results of a cadaveric study and an accompanying surgical technique which simplifies posterior-to-anterior axial screw placement into the calcaneus, often utilized during fixation of displaced intra-articular calcaneus fractures or calcaneal osteotomies. By defining the Tuber-to-Anterior Process Angle (TAPA), this technique facilitates axial screw placement, thereby decreasing reliance on intraoperative fluoroscopy and reducing operative time.

Introduction Properly placed tibial and femoral tunnels in anterior cruciate ligament (ACL) reconstruction are important because tunnel misplacement can cause abnormal changes in graft tension patterns, resulting in postoperative knee laxity. To overcome the inaccuracy of tunnel position in ACL reconstruction, intraoperative fluoroscopy has been proven to be a useful method in previous studies focusing on the tunnel position in single-bundle reconstruction, but few studies are available on the efficacy and necessity of intraoperative fluoroscopy for double-bundle (DB) reconstruction. The purpose of this prospective randomized case-control study was to evaluate the effect of intraoperative fluoroscopy on femoral and tibial tunnel position in anatomic DB ACL reconstruction using a postoperative tunnel position in a three-dimensional computed tomography (3D-CT). Hypothesis Intraoperative fluoroscopy during ACL DB reconstruction could make an appropriate tunnel position closer to the anatomical center compared to conventional fluoroscopy-free procedure. Material and methods Sixty patients undergoing ACL DB reconstruction (30 fluoroscopy-free reconstruction group and 30 in fluoroscopy-assisted reconstruction group) were included in this prospective study, and randomly allocated into two groups. Mean values of the percentage distance of femoral and tibial tunnel center in a 3D-CT were compared between the two groups. Knee laxity (the anterior translation and pivot-shift grade) and clinical outcomes were also compared at the last follow-up. Results There was a significant difference only in femoral anteromedial (AM) bundle tunnel position, but not in femoral posterolateral (PL) bundle, tibial AM, or PL bundle tunnel position between the two groups. Femoral AM bundle tunnel in the fluoroscopy-assisted reconstruction group showed significantly (p = 0.005) deeper position compared to that in the fluoroscopy-free reconstruction group. There was no significant difference in anterior translation, pivot-shift grade, or clinical outcomes between the two groups. Discussion Fluoroscopy-assisted ACL DB reconstruction can make deeper placement of the femoral AM bundle than the conventional ACL DB reconstruction. Level of evidence II, prospective randomized controlled trial.

Occipitocervical fusion (OCF) is indicated for instability at the craniocervical junction (CCJ). Numerous surgical techniques, which evolved over 90 years, as well as unique anatomic and kinematic relationships of this region present a challenge to the neurosurgeon. The current standard involves internal rigid fixation by polyaxial screws in cervical spine, contoured rods and occipital plate. Such approach precludes the need of postoperative external stabilization, lesser number of involved spinal segments, and provides 95–100% fusion rates. New surgical techniques such as occipital condyle screw or transarticular occipito-condylar screws address limitations of occipital fixation such as variable lateral occipital bone thickness and dural sinus anatomy. As the C0–C1–C2 complex is the most mobile portion of the cervical spine (40% of flexion-extension, 60% of rotation and 10% of lateral bending) stabilization leads to substantial reduction of neck movements. Preoperative assessment of vertebral artery anatomical variations and feasibility of screw insertion as well as visualization with intraoperative fluoroscopy are necessary. Placement of structural and supplemental bone graft around the decorticated bony elements is an essential step of every OCF procedure as the ultimate goal of stabilization with implants is to provide immobilization until bony fusion can develop.

Background: Posterior cervical atlantoaxial pedicle screw fixation is a very effective treatment for atlantoaxial instability (AAI). However, due to the complex anatomy of the cranial-cervical junction, the accuracy and safety of posterior atlantoaxial pedicle screw placement remains extremely challenging. Objective: To quantitatively evaluate the safety and accuracy of the 3D navigation module to assist the posterior atlantoaxial fixation. Methods: A total of 20 AAI patients were selected between June 2014 and September 2015. The Mimics v10.1 and 3-matic software were used. The 3D navigation module was designed as a double-sided positioning hole guide with a guide rod. All patients underwent posterior atlantoaxial posterior pedicle screw fixation with 3D navigation module. The actual entry point and screw trajectory were measured after operation, which were compared with the ideal entry point and screw trajectory. The Japanese Orthopaedic Association (JOA) score was measured before and after surgery to evaluate the neurological function improvement. The average operation time, blood loss, and frequency of intraoperative fluoroscopy were counted. Results: The posterior atlantoaxial pedicle screw fixation with a 3D navigation module was successfully performed in all patients. A total of 80 atlantoaxial pedicle screws were implanted in the 20 patients. Postoperative CT scan showed that two pedicle screws deviated from the medial aspect of the atlas pedicle cortex and entered the spinal canal approximately 1 mm, without causing neurological complications. There was no significant difference between the ideal and actual entry points or ideal and actual screw trajectories of the atlas and axis (P > 0.05). The preoperative JOA score was 12.45 ± 1.15 and postoperative JOA score was 15.5 ± 0.89, with statistically significant difference (P < 0.05). Conclusion: It was safe and effective to use the 3D navigation module to assist the posterior atlantoaxial pedicle insertion, with a high accuracy of pedicle screw placement. Keywords: atlantoaxial instability, pedicle screw, 3D navigation module, rapid prototyping

The craniovertebral junction (CVJ) is a deep, anatomically complex region that is affected by a wide variety of pathologies. As a result, surgical approaches must be tailored to allow the surgeon to safely and effectively achieve appropriate surgical objectives. Currently, the transoral-transpharyngeal approach is most commonly used to reach the anterior CVJ. It can be modified with a Le Fort osteotomy or transmandibular osteotomy and circumglossal approach to expand the working area, particularly for large tumor resections. However, significant morbidities associated with traversing the oral cavity could occur in this approach, including postoperative bacterial meningitis, especially in the setting of intraoperative dural tears, the need for tracheostomy, pharyngeal wound dehiscence, dysphasia, changes in phonation, airway impairment, and suboptimal cosmetic outcomes. Recently, Wolinksy et al. described an anterior transcervical approach to the CVJ, which allowed for ventral brainstem and spinal cord decompression as well as odontoid resection while avoiding the oral cavity altogether. When combined with endoscopy, neuronavigation, and intraoperative fluoroscopy, the transcervical approach allows access to the ventral CVJ with the decreased risk of bacterial meningitis or other complications associated with a transoral or transnasal approach. In this chapter, we aim to describe the techniques, indications, advantages, and limitations of the anterior transcervical craniocervical approach.

Introduction Wrong level surgery is a preventable event in spine surgery. The thoracic spine given its length and anatomical landmarks remains the most challenging spine section for accurate localization during surgery. Traditionally, counting the ribs with intraoperative fluoroscopy is the preferred method. The incidence of 11 ribs instead of the conventional 12 ribs is not examined in current scientific literature, even though the incidence of 11 ribs may have a substantial impact on spinal procedures and the outcomes. This is especially relevant if patients have a potential surgical pathology of their thoracic spine. In this case series we sought to investigate the prevalence of 11 ribs in a trauma population. Methods A retrospective review was conducted of patients presenting with thoracolumbar fractures at our Level I Trauma Center between 2017 and 2018. CT scans were obtained and analyzed by counting the number of ribs. Results Out of 234 patients who were consulted for thoraco-lumbar fractures by spine specialists, 8 patients had 11 ribs which results in a prevalence of 3.4 % in this population. Within these 8 patients, 5 were male (62.5 %). Conclusions Spine surgeons should consider the possibility of numeric variation of ribs when evaluating thoracolumbar spine imaging. In a trauma population with spine fractures, the prevalence of 11 ribs is 3.4 %. Given the not insignificant prevalence of this variant in potentially surgical spine patients, the spine surgeon should remain vigilant of this anatomical variant.

Objective To evaluate the feasibility, safety, and effectiveness of CT-guided microcoil localization of solitary pulmonary nodules (SPNs) for guiding video-assisted thoracoscopic surgery (VATS). Materials and methods Between June 2016 and October 2019, 454 consecutive patients with 501 SPNs who received CT-guided microcoil localization before VATS in our institution were enrolled. The diameter of the nodules was 0.93 ± 0.49 cm, and the shortest distance from the nodules to the pleura was 1.41 ± 0.95 cm. The distal end of the microcoil was placed less than 1 cm away from the nodule, and the proximal end was placed outside the visceral pleura. VATS was performed under the guidance of implanted microcoils without the aid of intraoperative fluoroscopy. Results All 501 nodules were marked with microcoils. The time required for microcoil localization was 12.8 ± 5.2 minutes. Microcoil localization-related complications occurred in 179 cases (39.4%). None of the complications required treatment. A total of 463 nodules were successfully resected under the guidance of implanted microcoils. VATS revealed 38 patients with dislocated microcoils, of which 28 underwent wedge resection (21 cases under the guidance of the bleeding points of pleural puncture, 7 cases through palpation), 5 underwent direct lobectomy, and the remaining 5 underwent a conversion to thoracotomy. In 4 cases, a portion of the microcoil remained in the lung parenchyma. Conclusion CT-guided microcoil localization of SPNs is safe and reliable. Marking the nodule and pleura simultaneously with microcoils can effectively guide the resection of SPNs using VATS without the aid of intraoperative fluoroscopy.

Objective The risk of novel postoperative neurological events due to pedicle screw malpositioning in lumbar fusion surgery is minimized by using one of the several image-guided techniques for pedicle screw insertion. These techniques for guided screw insertion range from intraoperative fluoroscopy to intraoperative navigation. A practical technique consists of anatomical identification of the screw entry point followed by lateral fluoroscopy used for guidance during insertion of the screw. This technique is available in most clinics and is less expensive than intraoperative navigation. However, the safety of lateral fluoroscopy-guided pedicle screw placement with regard to novel postoperative neurological events due to screw malposition has been addressed only rarely in the literature. In this study the authors aimed to determine the rate of novel postoperative neurological events due to intraoperative and postoperatively established screw malpositioning during lateral fluoroscopy-assisted screw insertion. Methods Included patients underwent lateral fluoroscopy-assisted lumbosacral screw insertion between January 2012 and August 2017. The occurrence of novel postoperative neurological events was analyzed from patient files. In case of an event, surgical reports were screened for the occurrence of intraoperative screw malposition. Furthermore, postoperative CT scans were analyzed to identify and describe possible screw malposition. Results In total, 246 patients with 1079 screws were included. Novel postoperative neurological events were present in 36 patients (14.6%). In 8 of these 36 patients (3.25% of the total study population), the neurological events could be directly attributed to screw malposition. Screw malpositioning was caused either by problematic screw insertion with immediate screw correction (4 patients) or by malpositioned screws for which the malposition was established postoperatively using CT scans (4 patients). Three patients with screw malposition underwent revision surgery without subsequent symptom relief. Conclusions Lateral fluoroscopy-assisted lumbosacral screw placement results in low rates of novel postoperative neurological events caused by screw malposition. In the majority of patients suffering from novel postoperative neurological events, these events could not be attributed to screw malpositioning, but rather were due to postoperative neurapraxia of peripheral nerves, neuropathy, or intraoperative traction of nerve roots.

We describe the successful removal of a pelvic contraceptive coil in a symptomatic 46-year-old patient who had Essure devices for four years, using a combined hysteroscopy-laparoscopy-fluoroscopy approach. Following normal hysteroscopy, at laparoscopy the right Essure implant was disrupted and its outer nitinol coil had perforated the fallopian tube. However, the inner rod (containing polyethylene terephthalate) had migrated to an extrapelvic location, near the proximal colon. In contrast, the left implant was situated within the corresponding tube. Intraoperative fluoroscopy was used to confirm complete removal of the device, which was further verified by postoperative computed tomography. The patient's condition improved after surgery and she continues to do well. This is the first report to describe this technique in managing Essure complications remote from time of insertion. Our case highlights the value and limitations of preoperative and intraoperative imaging to map Essure fragment location before surgery.

The anatomic anterior cruciate ligament (ACL) reconstruction concept has developed in part from renewed interest in the insertional anatomy of the ACL, using surgical techniques that can reproduce this anatomy reliably and accurately during surgical reconstruction. Several technical tools are available to help identify and place the tibial and femoral grafts anatomically, including arthroscopic anatomic landmarks, a malleable ruler device, and intraoperative fluoroscopy. The changes in technique for anatomic tunnel placement in ACL reconstruction follow recent biomechanical and kinematic data that demonstrate improved time zero characteristics. A better re-creation of native ACL kinematics and biomechanics is achieved with independent femoral drilling techniques that re-create a central footprint single-bundle ACL reconstruction or double-bundle reconstruction. However, to date, limited short-term and long-term clinical outcome data have been reported that support using either of these techniques rather than a transtibial drilling technique. This lack of clear clinical advantage for femoral independent and/or double-bundle techniques may arise because of the potentially offsetting biologic incorporation challenges of these grafts when placed using these techniques or could result from modifications made in traditional endoscopic transtibial techniques that allow improved femoral and tibial footprint restoration.

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Symptomatic subfibular and/or lateral talocalcaneal impingement in pediatric patients may result from an accessory anterolateral talar facet (AALTF). This impingement may cause pain and disability and may limit athletic performance in high-level athletes. We report the case of a 12-year-old female competitive gymnast who had refractory, lateral-sided right ankle pain for 4 months and underwent right ankle arthroscopic resection of the AALTF causing impingement. Standard medial and anterolateral portals with the addition of an accessory anterolateral-distal portal were used in conjunction with a 30° 2.7-mm-diameter arthroscope. The AALTF was resected with a combination of a shaver and a motorized rasp. Intraoperative fluoroscopy was used to verify successful debridement of the bony facet. This case illustrates that arthroscopic debridement is a technique to treat subfibular and/or talocalcaneal impingement associated with an AALTF.

Objectives To investigate if intraoperative 3D flat panel imaging improves the detection of radiocarpal intraarticular screw misplacement (RCSM) in comparison to standard postoperative x-ray. Methods In a study on cadaver specimens, we evaluated the sensitivity and specificity to detect RCSM using X-ray, intraoperative 3D-fluoroscopy as well as the digital volume tomography. The gold standard reference was computed tomography. Results Sensitivity for the detection of RCSM for X-ray was 58% and specificity 88%. For DVT, the sensitivity to detect RCSM was 88% and the specificity 53%. For 3D-fluoroscopy, the sensitivity for RCSM was 68% and specificity 95%. When combining the methods, the best performance was found, when combining the two intraoperative imaging methods, with a resulting sensitivity of 88% and a specificity of 73%. Conclusions Intraoperative 3D fluoroscopy and digital volume tomography appear to be at least as sensitive and specific to detect RCSM than the regular postoperative radiography in two planes. However, especially discrete screw misplacements can be missed with either method. Level of evidence Level IV. Diagnostic device study.

Thoracolumbar fractures are usually treated by open posterior pedicle screw fixation. However, this procedure involves massive paraspinal muscle stripping, inflicting surgical trauma, and prolonged X-ray exposure. In this study, we observed 127 patients with single-segment injury thoracolumbar fractures. Thirty-six patients were treated by the modified Wiltse's paraspinal approach with minimally invasive channel system, while 91 patients were treated via traditional posterior approach. Operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, screw placement accuracy, visual analogue scale score, and Cobb's angle of two groups were compared. The X-ray exposure times were notably reduced (4.2±1.6) in the new approach group (P

Purpose: The purpose of this study was to investigate the surgical outcomes of total hip arthroplasty (THA) through direct anterior approach (DAA) performed by beginners by comparing the outcomes after the introduction of DAA-THA between using a normal operating table and a traction table. Methods: The total subjects were 200 patients, there were 120 cases from the introduction of three surgeons using a normal table and 80 cases from two surgeons using a traction table. The surgical procedure was standardized, and a surgeon skilled in DAA entered the operating room and instructed the novice surgeons of DAA in all cases. Results: The mean operative time was no significant difference between the two groups ( p = 0.093). The difference in slope of the operative time was no significant difference between the two groups ( p value = 0.089). The mean fluoroscopy time and the mean blood loss were significant difference between the two groups ( p < 0.05). The difference in slope of the fluoroscopy time and blood loss were significant difference between the two groups ( p < 0.05). There were no intraoperative complications and no reoperations for any reason. Conclusions: At the facility with a surgeon skilled in DAA, the use of a traction table in DAA did not increase the complication rate compared with the use of a normal operating table when the exclusion criteria for DAA were set and surgery was performed using intraoperative fluoroscopy under supervision by a skilled surgeon.

Objective We designed a method for inserting C1 pedicle screws using the direct visualization technique of the pedicle and serial dilatation technique to reduce complications and malposition of screw, and assessed the accuracy of this method. Methods Free-hand C1 pedicle screw insertion using the direct visualization technique of the pedicle and serial dilatation technique was performed on 5 consecutive patients with C1–2 instability at a single institute from March to December 2018. The method involved protecting the vertebral artery (VA) and C1 root using the Penfield No. 1, securing the entry point of the posterior arch screw and the pedicle was visible directly in Trendelenburg position. The hole at the entry point of the C1 posterior arch was serially dilated using a 2.5×3.0 mm drill bit, and the C1 pedicle screw was inserted with the free hand technique. We measured postoperative radiological parameters and recorded intraoperative complications, postoperative neurological deficits and the occurrence of occipital neuralgia. Postoperative computed tomography (CT) was performed to check screw malposition or construction failure. Results Of the 10 C1 pedicle screws on postoperative CT, 20% of screws (grade A) were in the ideal position while 80% of screws (grade B) occupied a safe position. Overall, 100% of screws were safe (grade A or B). There were no iatrogenic neurological deficits, VA injury. Conclusion Freehand placement of the C1 pedicle screw through the direct visualization technique of the pedicle and serial dilatation technique is safe and effective without intraoperative fluoroscopy guidance.

Purpose: Intraoperative precise visualization of fractures and assessment of the quality of reduction is essential in orthopedic trauma surgery. Fluoroscopic skills will lead to an increased detection rate of minimal abnormalities needing revision intraoperatively. The definition of fluoroscopic skills and the interpretation of acceptable “minimal abnormalities” remains somehow unclear. The purpose of this study was to analyze the subjective quality assessment of intraoperative radiographs (IR) and whether they are influenced by cultural and demographic factors. Furthermore, we aimed to answer the question whether the indication for revision surgery is international comparable or rather influenceable by cultural aspects. Methods: Intraoperative radiographs of 30 patients operated for an ankle or radius fracture were selected for an international survey. In total, 22 patients were randomly selected from an already existing database and eligible for inclusion if reduction was accomplished during initial operation without planed revision. Eight patients of this group had undergone an unplanned revision surgery (26.6%). Fifteen orthopedic trauma surgeons from three different countries answered this survey. All raters were senior consultants. Results: The quality of reduction was rated as good in both the AP (7.95 of 10) and lateral (7.84 of 10) views. The inter-observer reliability was substantially weaker in Country B (kappa of 0.23) compared to Countries A (p value < 0.05) and C (range 0.33–0.43). In only 33% of the cases the raters requested a postoperative radiograph. This was significantly fewer (p value < 0.001) in Country A. The frequency of postoperative requested CT’s was comparable between the countries. Conclusion: This study showed acceptable IR assessment in terms of quality rating. Furthermore, it revealed substantial differences in the postoperative decision-making process in different countries, especially regarding the necessity for postoperative radiographs. This suggests that definition for indication of revision surgery is culturally influenced.

Diagnostic radiographs, computed tomography (CT), nuclear medicine studies, and intraoperative fluoroscopy durations were analyzed for radiation exposure. Cumulative and yearly effective ionizing radiation doses, cumulative background radiation, and total radiograph studies were compared between pediatric and adult populations. In 24 patients with 1,246 imaging studies (average 5.5 years longitudinal treatment duration), the mean estimated cumulative effective radiation dose per patient was 30.0 mSv (range 2.3–115.0), with an average yearly dose of 4.9 mSv (range 0.4–24.8). Pediatric patients had significantly more radiograph studies per year than adults and greater average yearly effective radiation doses.

Objective Catheter malposition represents one of the major causes of ventriculoperitoneal (VP) shunt dysfunction. The usefulness of intraoperative fluoroscopy using skull landmarks has already been proved to decrease catheter malposition and surgical revision rates. After introducing intraoperative computed tomography (iCT) in our department, our objective was to evaluate the accuracy of this imaging modality to decrease cranial catheter misplacement compared with intraoperative fluoroscopy. Methods In our retrospective analysis of 152 patients, catheter placement was evaluated by iCT (n = 48) and biplane fluoroscopy (n = 57). A control group (n = 47) had no intraoperative imaging. Outcome measures included accuracy of ventricular catheter position, revision surgeries, and clinical outcomes. Results Ventricular catheter placement was accurate in 24/48 patients with iCT and 45/57 patients with fluoroscopy (P = 0.002) versus 23/47 patients in the control group. Sensitivity and positive predictive value for estimating optimal catheter position with iCT were 100% and 54%. The specificity and negative predictive value were 50% and 100%. After intraoperative revision, 4 catheters remained malpositioned in the iCT group, whereas the fluoroscopy group had none (P = 0.03); 2 of these 4 catheters were revised postoperatively. Conclusions Fluoroscopy may be the method of choice to intraoperatively assess ventricular catheter positioning. In our experience, iCT shows a tendency to be more time consuming and, in the beginning, was not associated with a steeper learning curve. Another consideration was the significant higher radiation exposure per patient. iCT did not improve the accuracy of catheter placement and did not decrease early revisions for VP placement patients.

The aim of this study was to compare the radiological and clinical outcomes of clavicular hook plate fixation and the coracoclavicular lag screw supplemented with K-wire fixation in the treatment of acute acromioclavicular joint dislocation.Between January 2012 to December 2015, 81 patients with acute acromioclavicular joint dislocation were included in this prospective study. 43 patients were treated with clavicular hook plate fixation (Group A) and 38 patients were treated with coracoclavicular lag screw supplemented with K-wire fixation (Group B). Incision length, operation duration, blood loss volume, intraoperative fluoroscopy times and length of hospitalization were recorded. Radiographic outcomes, functional outcomes and complications were also recorded.Both two groups could achieve good radiographic and functional outcomes after operation. Group B exhibited significantly shorter operation duration, shorter length of incision, less blood loss volume and shorter length of hospitalization than Group A (P 0.001). In addition, significant difference could be found between the two groups regarding the VAS scores three month postoperatively and the final follow-up (P 0.001). However, there was no significant difference in radiographic and functional outcomes between the two groups (P 0.05).The two groups can both achieve satisfactory radiological and functional outcomes in treating acute AC joint dislocation. However, CC screw fixation supplemented with K-wire exerts some advantages regarding the incision length, operation duration, blood loss volume, length of hospitalization. Furthermore, it can better relieve the pain caused by dislocation. Therefore, the novel hybrid fixation (CC screw fixation supplemented with K-wire) provides an alternative treatment for acute AC joint dislocation.

Malpositioning of the cup in total hip arthroplasty (THA) is associated with dislocation, early polyethylene wear, and impingement. The direct anterior approach (DAA) THA allows for intraoperative fluoroscopy imaging (IF). The current study investigates the following research hypotheses: (1) intraoperative measurements of radiographic cup inclination (RI) are reliable and reproducible. (2) A correction factor can compensate for the complex parallax effects when using IF. In 2016, 100 consecutive hips underwent primary THA utilizing DAA and IF for cup placement. RI was measured on intraoperative fluoroscopy images and postoperative AP pelvis radiographs. Determination of RI on IF images is reliable and reproducible (ICC 0.851–0.950). RI measurement on IF images had a good correlation with the corresponding postoperative RI on AP pelvis radiographs (r = 0.538, p

Preoperative evaluation of the contralateral anatomic lateral distal femoral angle (aLDFA) at our institution is used to judge coronal plane alignment. In our study, we investigated 4 different techniques for obtaining an anteroposterior intraoperative fluoroscopic image of the distal femur to determine which technique provides (1) the greatest interobserver reliability; (2) the lowest variability from the previously published population mean; and (3) the lowest side-to-side variability.Inclusion criteria included lower extremity injuries needing fixation that required intraoperative fluoroscopy with an intact femur and an intact extensor mechanism (N = 100). Fluoroscopic images were obtained of the distal femur in 4 positions differentiated by the position of the limb and the orientation of the C-arm beam to the femoral shaft.All measurement techniques resulted in mean measurements within one degree of 81 degrees. Variance between measurements was small among patients with all views, but images that involved a true anteroposterior with the beam perpendicular to the femur had the lowest rate of measurements that were78 or84 degrees.Side-to-side differences in patients were2 degrees on average with every image used. With the best-performing images, 20% of patients had an aLDFA3 degrees different from the population mean of 81 degrees and 3% of patients were5 degrees different. Although restoring aLDFA to 81 degrees will be within 3 degrees of the contralateral side the vast majority of the time, matching the aLDFA to the injured side will be the most accurate reconstruction.

Study design Retrospective analysis; single center data. Objective The purpose of this study is to look at the utility and relevance of immediate postoperative radiographs in providing vital information leading to immediate revision after spine surgery. Summary of background data Immediate postoperative radiographs are routinely obtained in the recovery room after spine surgery to verify the level, alignment of the spine, implant position, and the adequacy of the procedure. However, with the ability to utilize intraoperative fluoroscopy imaging for the same purpose, the requirement for immediate postoperative radiographs needs to be validated. The purpose of this study is to look at the utility and relevance of these postoperative radiographs in providing critical information that may warrant immediate intervention. Methods Retrospective analysis of all spine surgeries (elective and emergent), performed at a single center from 2011 to 2016, was done and cases returning to operating room within 48 hours were identified. Indication of immediate revision was reviewed and utility of immediate postoperative radiographs in guiding immediate revision was analyzed. Results A total of 1804 elective and urgent spinal surgeries were performed by seven surgeons. Twenty-two patients returned to operating room within 48 hours of their index procedures. Of these 22 cases, only two patients were noted to have positive findings on recovery room radiographs. The findings of suboptimal spinal alignment or failed instrumentation led to the immediate revision in both cases. Both cases involved instrumentation at cervicothoracic region and intraoperative imaging provided only limited visualization. Conclusion Routine recovery room radiographs played a role in the decision to emergently return to the operating room in 0.10% (2/1804) cases at our institution. The potential benefit of immediate recovery room radiographs after spine surgery should be weighed against the added healthcare cost and patient discomfort associated with obtaining these radiographs routinely. Imaging may be delayed to a more elective time without any significant risk in majority of spine cases. Level of evidence 3.

This study investigated the clinical feasibility and application value of computer virtual reduction combined with three-dimensional (3D) printing technique in patients with complex acetabular fracture. Ninety-six patients diagnosed with complex acetabular fracture in the Orthopedics Department in The Second Affiliated Hospital of Luohe Medical College from January 2016 to June 2017 were selected and randomly divided into the routine operation group (n=48) and the 3D model group (n=48) according to the admission number of the patients. In the 3D model group, computed tomography (CT) scan was performed preoperatively, and the model was made using the virtual technique and 3D printing technique. The surgical scheme was designed according to the model. Patients in the routine operation group were diagnosed with the conventional CT scan without using the computer virtual technique and 3D printing technique. During operation, the operation time, amount of intraoperative bleeding and times of intraoperative fluoroscopy were recorded in both groups. After operation, the incidence rate of such complications as inflammatory response, iatrogenic neurological symptoms and loss of reduction were recorded in both groups. Moreover, the reduction quality of acetabular fracture was evaluated according to the Matta imaging score at 3 days after operation, and the hip joint function was evaluated based on the Hariss score at 6 months after operation. In the 3D model group, the operation time was significantly shorter than that in the control group, the amount of intraoperative bleeding and times of intraoperative fluoroscopy were significantly less than those in the routine operation group, and the incidence rate of postoperative complications was obviously lower than that in the routine operation group (P

Purpose Cement leakage is a typical complication of kyphoplasty for vertebral fractures. It is unclear if cement application intraoperatively can be improved by using other techniques of visualization and which kind of postoperative imaging should be recommended to detect cement extravasation accurately. Objective To compare the rates of cement leakage detected by intraoperative fluoroscopy, postoperative radiography, and postoperative computed tomography (CT) in a retrospective study. Patients and Methods The study included 78 patients (60 women and 18 men; 115 vertebral bodies) who were treated with two kinds of kyphoplasty. The patients underwent intraoperative fluoroscopy and postoperative radiography and CT. After surgery, the images were evaluated to compare cement leakage rates and locations in the three visualization techniques. Leakage locations were described as epidural, intradiskal, extravertebral, or intravascular. Results Compared with CT, intraoperative fluoroscopy regularly detected intradiskal leakage (75%) but had a considerably lower sensitivity for visualizing epidural (21%), extravertebral (31%), and intravascular (51%) cement leakages. A comparison of radiography and CT showed that radiography had a high sensitivity for detecting intradiskal (82%) and intravascular (70%) cement extrusions but a lower sensitivity in identifying epidural (42%) and extravertebral (50%) leaks. Therefore, the CT scan overall was best in detecting location and accuracy. Conclusion CT detected more cement leaks than any of the other investigated techniques, especially epidural, extravertebral, and intravascular cement leakages. To achieve the best accuracy, only CT provides complete information.

Orthopaedic surgeons are routinely exposed to intraoperative radiation and, therefore, follow the principle of "as low as reasonably achievable" with regard to occupational safety. However, standardized education on the long-term health effects of radiation and the basis for current radiation exposure limits is limited in the field of orthopaedics. Much of orthopaedic surgeons' understanding of radiation exposure limits is extrapolated from studies of survivors of the atomic bombings in Hiroshima and Nagasaki, Japan. Epidemiologic studies on cancer risk in surgeons and interventional proceduralists and dosimetry studies on true radiation exposure during trauma and spine surgery recently have been conducted. Orthopaedic surgeons should understand the basics and basis of radiation exposure limits, be familiar with the current literature on the incidence of solid tumors and cataracts in orthopaedic surgeons, and understand the evidence behind current intraoperative fluoroscopy safety recommendations.

Background Iliac screw placement is challenging due to the particular anatomy of the ilium. Most series have reported the use of relatively short (≤90 mm in length) screws despite a long iliac buttress, which has an average length of 129 mm in females and 141 mm in males. This study describes a series of 14 patients who underwent placement of long iliac screws (≥100 mm in length) as part of a spinopelvic fusion utilizing fluoroscopy alone. Methods All patients who received at least one long iliac screw were included in this study. Placement accuracy, the average distance from the screw tip to the anterior inferior iliac spine (AIIS), neurovascular injuries, acetabulum and/or sciatic notch violations, and screw prominence were all measured. Results Fourteen patients received 38 iliac screws, with 31 screws being ≥100 mm in length. The accuracy rate was 87.1% (27/31) for the long iliac screws. The average shortest distance from the iliac screw tip to the AIIS was 15.5 mm for the right-sided and 17.1 mm for the left-sided ilia. There were no neurovascular injuries, acetabulum, or sciatic notch violations, and no screws loosened or fractured. Of interest, only one patient required off-set connectors to link the rods to the iliac screws. Conclusions Placement of long iliac screws under intraoperative fluoroscopy only was shown to be feasible, with a high accuracy rate and few complications, in this series of patients.

Purpose The purpose of this prospective cohort study of patients treated with volar plating for distal radius fractures is to evaluate the efficacy (defined as detection rate, or the ability to detect dorsally protruding screws) of additional dorsal tangential views (DTV) after obtaining standard anteroposterior (AP) and elevated lateral views by evaluating the change in intraoperative strategy in 100 patients. Materials and methods 100 patients aged 18 years and older undergoing volar plating for acute extra- or intra- articular distal radius fractures were prospectively enrolled. Intraoperative fluoroscopy views, including AP, elevated lateral and DTV were obtained. Intraoperative –screw– revision frequency for dorsal screw protrusion, screw position relative to volar plate and to dorsal compartment, and screw lengths were evaluated. Results Additional DTV led to a change of intraoperative management in 31 of 100 (31%) of patients. A total of 35 out of 504 screws (6.9%) were changed. Screws in the two most radial screws in the plate were at the highest risk of being revised; 16 (46%) screws in most radial position and nine (26%) screws in the 2nd from radial position were revised. Furthermore, five (14%) screws in both the 2nd from ulnar and most ulnar screw holes were revised after DTV. No screws were revised in the central hole. The median length of revised protruding screws was 22 mm (range, 12–26 mm), and these were changed to a mean length of 20 mm (range, 10–22 mm). Conclusion In this prospective series of 100 patients, obtaining additional DTV is found to be efficacious as it led to change in intraoperative strategy in one-third of patients. We concur with previous pilot studies that DTV, after obtaining conventional AP and elevated lateral views, is advised to avoid dorsally protruding screws, which could minimise the potential for iatrogenic extensor tendon rupture after volar plating for distal radius fractures. Diagnostic accuracy of DTV is subject of a subsequent prospective cohort study with post-operative CT to serve as the reference standard. Level of evidence .Prognostic I