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Pisquiy JJ, Toraih EA, Hussein MH, Khalifa R, Shoulah SA, Abdelgawad A, Thabet AM. Utility of 3-Dimensional Intraoperative Imaging in Pelvic and Acetabular Fractures: A Network Meta-Analysis. JBJS Rev 2021; 9:01874474-202106000-00013. [PMID: 34166271 DOI: 10.2106/jbjs.rvw.20.00129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Successful surgical management of pelvic ring and acetabular fractures requires technical expertise to achieve an accurate reduction and stable fixation. The use of 3-dimensional (3D) intraoperative imaging (3DIOI) as an assessment tool has led to improved reduction and placement of implants. The purpose of this study was to assess the utility of using 3DIOI in the management of acetabular and pelvic fractures on the basis of outcomes reported in the literature. METHODS A literature search was performed using PubMed, the Cochrane Database of Systematic Reviews (CDSR), and Google Scholar using key terms. A network meta-analysis conducted using the frequentist approach allowed for statistical analysis of reported outcomes regarding screw position (in mm), fracture reduction (in mm), and complications. RESULTS A total of 9 studies were included in this analysis. When compared with conventional radiography, the mean radiation dose (in cGy·cm2) was significantly higher in 3DIOI (mean difference, 82.72; 95% confidence interval [CI], 21.83 to 143.61; p = 0.007). Use of 3DIOI yielded a 93% lower risk of developing medical complications (odds ratio [OR], 0.07; 95% CI, 0.02 to 0.35; p = 0.014). Use of 3DIOI yielded higher odds of achieving accurate screw placement (OR, 4.21; 95% CI, 1.44 to 12.32; p = 0.008) and perfect reduction (OR, 2.60; 95% CI, 1.19 to 5.68; p = 0.016). In ranking the imaging modalities, 12 of the 13 parameters analyzed were in favor of 3DIOI over conventional fluoroscopy and 2D navigation imaging. CONCLUSIONS Current literature supports the use of 3DIOI because of the decreased rates of misplaced implants, malreduced fractures, complications, and subsequent revision operations. The use of 3DIOI allows for improved visualization of pelvic anatomy when repairing pelvic and acetabular fractures, and helps surgeons to achieve favorable surgical outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- John J Pisquiy
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center El Paso, El Paso, Texas.,Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Eman A Toraih
- Department of Surgery, Tulane University, New Orleans, Louisiana
| | | | - Rami Khalifa
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center El Paso, El Paso, Texas.,Department of Orthopaedics, Al Helal Hospital, Cairo, Egypt
| | - Saad A Shoulah
- Department of Orthopaedic Surgery, Benha University School of Medicine, Benha, Egypt
| | - Amr Abdelgawad
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Ahmed M Thabet
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
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Pennington Z, Cottrill E, Westbroek EM, Goodwin ML, Lubelski D, Ahmed AK, Sciubba DM. Evaluation of surgeon and patient radiation exposure by imaging technology in patients undergoing thoracolumbar fusion: systematic review of the literature. Spine J 2019; 19:1397-1411. [PMID: 30974238 DOI: 10.1016/j.spinee.2019.04.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive spine techniques are becoming increasingly popular owing to their ability to reduce operative morbidity and recovery times. The downside to these new procedures is their need for intraoperative radiation guidance. PURPOSE To establish which technologies provide the lowest radiation exposure to both patient and surgeon. STUDY DESIGN/SETTING Systematic review OUTCOME MEASURES: Average intraoperative radiation exposure (in mSv per screw placed) to surgeon and patient. Average fluoroscopy time per screw placed. METHODS We reviewed the available English medical literature to identify all articles reporting patient and/or surgeon radiation exposure in patients undergoing image-guided thoracolumbar instrumentation. Quantitative meta-analysis was performed for studies providing radiation exposure or fluoroscopy use per screw placed to determine which navigation modality was associated with the lowest intraoperative radiation exposure. Values on meta-analysis were reported as mean ± standard deviation. RESULTS We identified 4956 unique articles, of which 85 met inclusion/exclusion criteria. Forty-one articles were included in the meta-analysis. Patient radiation exposure per screw placed for each modality was: conventional fluoroscopy without navigation (0.26±0.38 mSv), conventional fluoroscopy with pre-operative CT-based navigation (0.027±0.010 mSv), intraoperative CT-based navigation (1.20±0.91 mSv), and robot-assisted instrumentation (0.04±0.30 mSv). Values for fluoroscopy used per screw were: conventional fluoroscopy without navigation (11.1±9.0 seconds), conventional fluoroscopy with navigation (7.20±3.93 s), 3D fluoroscopy (16.2±9.6 s), intraoperative CT-based navigation (19.96±17.09 s), and robot-assistance (20.07±17.22 s). Surgeon dose per screw: conventional fluoroscopy without navigation (6.0±7.9 × 10-3 mSv), conventional fluoroscopy with navigation (1.8±2.5 × 10-3 mSv), 3D Fluoroscopy (0.3±1.9 × 10-3 mSv), intraoperative CT-based navigation (0±0 mSv), and robot-assisted instrumentation (2.0±4.0 × 10-3 mSv). CONCLUSION All image guidance modalities are associated with surgeon radiation exposures well below current safety limits. Intraoperative CT-based (iCT) navigation produces the lowest radiation exposure to surgeon albeit at the cost of increased radiation exposure to the patient relative to conventional fluoroscopy-based methods.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA.
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Nachabe R, Strauss K, Schueler B, Bydon M. Radiation dose and image quality comparison during spine surgery with two different, intraoperative 3D imaging navigation systems. J Appl Clin Med Phys 2019; 20:136-145. [PMID: 30677233 PMCID: PMC6370984 DOI: 10.1002/acm2.12534] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/07/2018] [Accepted: 12/22/2018] [Indexed: 12/20/2022] Open
Abstract
Careful protocol selection is required during intraoperative three-dimensional (3D) imaging for spine surgery to manage patient radiation dose and achieve clinical image quality. Radiation dose and image quality of a Medtronic O-arm commonly used during spine surgery, and a Philips hybrid operating room equipped with XperCT C-arm 3D cone-beam CT (hCBCT) are compared. The mobile O-arm (mCBCT) offers three different radiation dose settings (low, standard, and high), for four different patient sizes (small, medium, large, and extra large). The patient's radiation dose rate is constant during the entire 3D scan. In contrast, C-CBCT spine imaging uses three different field of views (27, 37, and 48 cm) using automatic exposure control (AEC) that modulates the patient's radiation dose rate during the 3D scan based on changing patient thickness. hCBCT uses additional x-ray beam filtration. Small, medium, and large trunk phantoms designed to mimic spine and soft tissue were imaged to assess radiation dose and image quality of the two systems. The estimated measured "patient" dose for the small, medium, and large phantoms imaged by the mCBCT considering all the dose settings ranged from 9.4-27.6 mGy, 8.9-33.3 mGy, and 13.8-40.6 mGy, respectively. The "patient" dose values for the same phantoms imaged with hCBCT were 2.8-4.6 mGy, 5.7-10.0 mGy, and 11.0-15.2 mGy. The CNR for the small, medium, and large phantoms was 2.9 to 3.7, 2.0 to 3.0, and 2.5 to 2.6 times higher with the hCBCT system, respectively. Hounsfield unit accuracy, noise, and uniformity of hCBCT exceeded the performance of the mCBCT; spatial resolution was comparable. Added x-ray beam filtration and AEC capability achieved clinical image quality for intraoperative spine surgery at reduced radiation dose to the patient in comparison to a reference O-arm system without these capabilities.
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Affiliation(s)
- Rami Nachabe
- Image Guided Therapy SystemsPhilips HealthcareBestThe Netherlands
| | - Keith Strauss
- Department of RadiologyCincinnati Children's HospitalCincinnatiOHUSA
| | - Beth Schueler
- Department of Neurologic RadiologyMayo ClinicRochesterMNUSA
| | - Mohamad Bydon
- Department of Neurologic SurgeryMayo ClinicRochesterMNUSA
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Prod’homme M, Sans-Merce M, Pitteloud N, Damet J, Lascombes P. Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study. J Child Orthop 2018; 12:550-557. [PMID: 30294382 PMCID: PMC6169555 DOI: 10.1302/1863-2548.12.180016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Exposure to ionizing radiation is a concern for children during intraoperative imaging. We aimed to assess the radiation exposure to the paediatric patient with 2D and 3D imaging. METHODS To evaluate the radiation exposure, patient absorbed doses to the organs were measured in an anthropomorphic phantom representing a five-year-old child, using thermoluminescent dosimeters. For comparative purposes, organ doses were measured using a C-arm for one minute of fluoroscopy and one acquisition with an O-arm. The cone-beam was centred on the pelvis. Direct and scattered irradiations were measured and compared (Student's t-test). Skin entrance dose rates were also evaluated. RESULTS All radiation doses were expressed in µGy. Direct radiation doses of pelvic organs were between 631.22 and 1691.87 for the O-arm and between 214.08 and 737.51 for the C-arm, and were not significant (p = 0.07). Close scattered radiation on abdominal organs were between 25.11 and 114.85 for the O-arm and between 8.03 and 55.34 for the C-arm, and were not significant (p = 0.07). Far scattered radiation doses on thorax, neck and head varied from 0.86 to 6.42 for the O-arm and from 0.04 to 3.08 for the C-arm, and were significant (p = 0.02). The dose rate at the skin entrance was 328.58 µGy.s-1 for the O-arm and 1.90 with the C-arm. CONCLUSION During imaging of the pelvis, absorbed doses for a 3D O-arm acquisition were higher than with one minute fluoroscopy with the C-arm. Further clinical studies comparing effective doses are needed to assess ionizing risks of the intraoperative imaging systems in children.
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Affiliation(s)
- M. Prod’homme
- Medical University of Geneva, Geneva, Switzerland,Paediatric Orthopaedic Division, Geneva University Hospital (HUG), Geneva, Switzerland, Correspondence should be sent to M. Prod’homme, Paediatric Orthopaedic Division, Geneva University Hospital (HUG), Rue Willy-Donzé 6, CH-1211 Geneva, Switzerland. E-mail:
| | - M. Sans-Merce
- Radiology Division, Geneva University Hospital (HUG), Geneva, Switzerland,Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland
| | - N. Pitteloud
- Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland,Physics Section, University of Geneva, Geneva, Switzerland
| | - J. Damet
- Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland,Department of Radiology, University of Otago, Christchurch, New Zealand
| | - P. Lascombes
- Medical University of Geneva, Geneva, Switzerland,Paediatric Orthopaedic Division, Geneva University Hospital (HUG), Geneva, Switzerland
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Takahata M, Yamada K, Akira I, Endo T, Sudo H, Yokoyama H, Iwasaki N. A novel technique of cervical pedicle screw placement with a pilot screw under the guidance of intraoperative 3D imaging from C-arm cone-beam CT without navigation for safe and accurate insertion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2754-2762. [DOI: 10.1007/s00586-018-5706-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 07/16/2018] [Indexed: 12/19/2022]
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Mu H, Sun J, Li L, Yin J, Hu N, Zhao W, Ding D, Yi L. Ionizing radiation exposure: hazards, prevention, and biomarker screening. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2018; 25:15294-15306. [PMID: 29705904 DOI: 10.1007/s11356-018-2097-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/20/2018] [Indexed: 06/08/2023]
Abstract
Radiation is a form of energy derived from a source that is propagated through material in space. It consists of ionizing radiation or nonionizing radiation. Ionizing radiation is a feature of the environment and an important tool in medical treatment, but it can cause serious damage to organisms. A number of protective measures and standards of protection have been proposed to protect against radiation. There is also a need for biomarkers to rapidly assess individual doses of radiation, which can not only estimate the dose of radiation but also determine its effects on health. Proteomics, genomics, metabolomics, and lipidomics have been widely used in the search for such biomarkers. These topics are discussed in depth in this review.
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Affiliation(s)
- Hongxiang Mu
- Institute of Cytology and Genetics, College of pharmaceutical and biological science, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
| | - Jing Sun
- Institute of Cytology and Genetics, College of pharmaceutical and biological science, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
| | - Linwei Li
- Institute of Cytology and Genetics, College of pharmaceutical and biological science, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
| | - Jie Yin
- Institute of Cytology and Genetics, College of pharmaceutical and biological science, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
- Key Discipline Laboratory for National Defense for Biotechnology in Uranium Mining and Hydrometallurgy, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
| | - Nan Hu
- Key Discipline Laboratory for National Defense for Biotechnology in Uranium Mining and Hydrometallurgy, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
| | - Weichao Zhao
- Key Discipline Laboratory for National Defense for Biotechnology in Uranium Mining and Hydrometallurgy, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
| | - Dexin Ding
- Key Discipline Laboratory for National Defense for Biotechnology in Uranium Mining and Hydrometallurgy, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China
| | - Lan Yi
- Institute of Cytology and Genetics, College of pharmaceutical and biological science, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China.
- Key Discipline Laboratory for National Defense for Biotechnology in Uranium Mining and Hydrometallurgy, University of South China, Hengyang, 421001, Hunan Province, People's Republic of China.
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Low-Dose Radiation 3D Intraoperative Imaging: How Low Can We Go? An O-Arm, CT Scan, Cadaveric Study. Spine (Phila Pa 1976) 2017; 42:E1311-E1317. [PMID: 28296816 DOI: 10.1097/brs.0000000000002154] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED MINI: The objective of this study was to evaluate the accuracy and reliability of pedicle screw placement using O-Arm at dosages below the manufactured recommended dose. O-Arm at reduced dose showed a 90% accuracy when compared with computed tomography; however, about 30% medial breaches were misclassified. STUDY DESIGN Cadaveric study. OBJECTIVE The objective was to evaluate O-Arm's ability at low-dose (LD) settings to assess intraoperative screw placement. SUMMARY OF BACKGROUND DATA Accurate placement of pedicle screws is crucial because of proximity to vital structures. Malposition of screws may result in significant morbidity and potential mortality. O-arm provides real-time, intraoperative imaging of patient's anatomy and provides higher accuracy in scoliosis surgeries, avoiding risk to vital structures. We hypothesize using LD or ultra-low doses (ULDs) to obtain intraoperative images allow for accurate assessment of screw placement, both minimizing radiation exposure and preventing screw misplacement. METHODS Eight cadavers were instrumented with pedicle screws bilaterally from T1 to S1. Screws were randomly placed using O-arm navigation into three positions: contained within the bone, OUT-anterior/lateral, and OUT-medial. O-arm images were obtained at three dosage settings: LD (kVp120/mAs125-lowest manufacturer recommended), very-low dose (VLD) (kVp120/mAs63), and ULD (kVp120/mAs39). Computed tomography (CT) scan was performed using institution's LD protocol (kVp100/mAs50) and gross dissection to identify screw positions. RESULTS LD, VLD, ULD, and CT for identifying "IN" screws relative to gross dissection had, a mean (standard deviation) sensitivity of 84.2% (±5.7), specificity of 76.1% (±9.3), and accuracy of 79.9% (±3.1) from all three observers. Across the three observers, the interobserver agreement was 0.67 (0.61-0.72) for LD, 0.74 (0.69-0.79) for VLD, 0.61 (0.56-0.66) for ULD, and 0.79 (0.74-0.84) for CT. Effective doses of radiation (mSV) for LD O-arm scan was 2.16, VLD 1.08, ULD 0.68, and our LD CT protocol was 1.05. CONCLUSION Accuracy of pedicle screw placement is similar for O-arm at all doses and CT compared to gross dissection. Interobserver reliability was substantial for VLD and CT. Approximately 30% of medial screw breaches are, however, misclassified. ULD and VLDs can be used for intraoperative navigation and evaluation purposes within these limitations. LEVEL OF EVIDENCE N/A.
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Hazards of Ionizing Radiation and its Impact on Spine Surgery. World Neurosurg 2016; 92:353-359. [DOI: 10.1016/j.wneu.2016.05.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 12/28/2022]
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Eckardt H, Lind D, Toendevold E. Open reduction and internal fixation aided by intraoperative 3-dimensional imaging improved the articular reduction in 72 displaced acetabular fractures. Acta Orthop 2015; 86:684-9. [PMID: 26012545 PMCID: PMC4750767 DOI: 10.3109/17453674.2015.1055690] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE During acetabular fracture surgery, the acetabular roof is difficult to visualize with 2-dimensional fluoroscopic views. We assessed whether intraoperative 3-dimensional (3D) imaging can aid the surgeon to achieve better articular reduction and improve implant fixation. PATIENTS AND METHODS We operated on 72 acetabular fractures using intraoperative 3D imaging and compared the operative results, duration of surgery, and complications with those for 42 consecutive acetabular fracture operations conducted using conventional fluoroscopic imaging. Postoperative reduction was evaluated on reconstructed coronal and sagittal images of the acetabulum. RESULTS The fracture severity and patient characteristics were similar in the 2 groups. In the 3D group, 46 of 72 patients (0.6) had a perfect result after open reduction and internal fixation, and in the control group, 17 of 42 (0.4) had a perfect result. The mean difference in postoperative articular incongruity was 0.5 mm (95% CI: 0.4-0.7). In 29 of 72 operations, the intraoperative 3D scans led to intraoperative correction of the reduction and an improved result. The duration of surgery and infection rate were similar in the 2 groups. INTERPRETATION Intraoperative 3D imaging, which is not time-consuming, allowed the surgeon to correct malreductions and screw placement in 29 of 72 operations, leading to better articular reduction and more precise screw placement than in operations where conventional fluoroscopic imaging was used to control the reduction.
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Affiliation(s)
- Henrik Eckardt
- Unispital Basel, Department of Trauma, Basel, Switzerland,Correspondence:
| | - Dennis Lind
- Orthopedic Department, Skåne University Hospital, Malmö, Sweden
| | - Erik Toendevold
- Department of Orthopedic Trauma, Rigshospitalet University Hospital, Copenhagen, Denmark
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Eckardt H, Lind M. Effect of Intraoperative Three-Dimensional Imaging During the Reduction and Fixation of Displaced Calcaneal Fractures on Articular Congruence and Implant Fixation. Foot Ankle Int 2015; 36:764-73. [PMID: 25761853 DOI: 10.1177/1071100715576518] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Operative treatment of displaced calcaneal fractures should restore joint congruence, but conventional fluoroscopy is unable to fully visualize the subtalar joint. We questioned whether intraoperative 3-dimensional (3D) imaging would aid in the reduction of calcaneal fractures, resulting in improved articular congruence and implant positioning. METHOD Sixty-two displaced calcaneal fractures were operated on using standard fluoroscopic views. When the surgeon had achieved a satisfactory reduction, an intraoperative 3D scan was conducted, malreductions or implant imperfections were revised, the calcaneus was rescanned, and this sequence was repeated until the optimal operative result was achieved. RESULTS Five fractures underwent 1 intraoperative scan, 39 fractures underwent 2 scans, 13 fractures underwent 3 scans, and 5 fractures underwent 4 scans. The average number of scans was 2.3. Intraoperative scanning led to re-reduction and improvement of reduction in 13 fractures, change of plate position in 1 patient, optimizing of the screw directions in 5 fractures, and shortening of screws that were intra-articular or protruding medially in 6 fractures. The postoperative articular displacement was 0 mm in 69% of the Sanders type 2 fractures and 57% of the Sanders type 3 fractures. Operation duration averaged 118 minutes, and there were no reoperations due to misplaced screws or plates. The average absorbed radiation dose per patient was 288 mGy·cm. CONCLUSION Intraoperative 3D imaging improved the articular reduction of the posterior facet and secured optimal implant position in displaced calcaneal fractures. Radiation dose to the patient was less than that of a normal foot computed tomography scan. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Henrik Eckardt
- Department of Traumatology, Basel University Hospital, Basel, Switzerland
| | - Marianne Lind
- Department of Orthopaedic Traumatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Comparative radiation exposure using standard fluoroscopy versus cone-beam computed tomography for posterior instrumented fusion in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2014; 39:E850-5. [PMID: 24732839 DOI: 10.1097/brs.0000000000000363] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The objective of this study was to define the intraoperative radiation exposure during freehand surgical technique with fluoroscopic assistance for placement and confirmation of posterior instrumentation in patients with adolescent idiopathic scoliosis and compare data with published values using intraoperative cone-beam computed tomography (CBCT) for similar cases. SUMMARY OF BACKGROUND DATA The treatment of idiopathic-like scoliosis used freehand placement of posterior instrumentation with fluoroscopic confirmation. Computer-assisted navigation systems coupled with intraoperative CBCT have been introduced to aid in accurate placement of instrumentation. Multiple studies report the improved accuracy of instrumentation using CBCT; however, there is a paucity of information regarding the radiation exposure when using CBCT in comparison with fluoroscopically assisted freehand technique. METHODS Forty-three idiopathic-like scoliosis operations performed by 4 spine surgeons at an academic institution were retrospectively reviewed. Radiation exposure was recorded intraoperatively for each case. Effective dose was determined using published effective dose to dose-length product conversion factors. Values were compared with previous studies reporting radiation exposure for similar cases using CBCT for intraoperative navigation and confirmation of instrumentation placement. RESULTS Calculated average effective dose using fluoroscopically assisted pedicle screw placement was 0.189 mSv (range, 0.00029-0.953 mSv; SD = 0.16711) per case. Average radiation exposure time was 26 seconds (SD = 18 s) per case, with an average of 11 vertebral levels fused. The literature reports effective dose for CBCT ranging from 7.29 to 9.72 mSv per case for intraoperative navigation and 14.58 to 19.44 mSv per case for both intraoperative navigation and confirmation of screw placement with CBCT. CONCLUSION We have demonstrated that the use of standard fluoroscopy results in markedly lower radiation exposure during a standard posterior instrumented fusion for idiopathic-like scoliosis than by the use of CBCT; this conclusion is limited by the retrospective nature of the study and lack of a control group. LEVEL OF EVIDENCE 4.
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Rassweiler MC, Banckwitz R, Koehler C, Mueller-Allissat B, Michel MS, Häcker A, Ritter M. New developed urological protocols for the Uro Dyna-CT reduce radiation exposure of endourological patients below the levels of the low dose standard CT scans. World J Urol 2013; 32:1213-8. [DOI: 10.1007/s00345-013-1195-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/15/2013] [Indexed: 01/10/2023] Open
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Ling JM, Tiruchelvarayan R, Seow WT, Ng HB. Surgical treatment of adult and pediatric C1/C2 subluxation with intraoperative computed tomography guidance. Surg Neurol Int 2013; 4:S109-17. [PMID: 23646272 PMCID: PMC3642753 DOI: 10.4103/2152-7806.109454] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/28/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical treatment of C1/C2 subluxation has evolved significantly over the past 2 decades, from the relatively simpler posterior wiring to more technically demanding instrumentations such as C1 lateral mass screws - C2 pedicle screws, C1/C2 transarticular screws, and occipital cervical fusion. Navigation with fluoroscopy is currently the standard of practice in most centers. However, fluoroscopy at this level carries several major drawbacks, such as blockage by the mandible and inability to produce axial images for assessment of the reduction of rotatory subluxation. METHODS The authors report a series of 21 patients with C1/C2 subluxation treated surgically with intraoperative computed tomography (ICT) guidance. RESULTS There were 7 children and 14 adults. Eight patients underwent C1/C2 fixation with a Harm's construct, and 13 patients underwent occipital cervical fusion. One out of 17 (6%) C1 lateral mass screws has breached the medial wall of lateral mass by 1 mm. Two out of 20 (10%) C2 pedicle screws have breached the foramen transversarium by 1 mm (Neo classification grade 1). The position of all subaxial screws (49 lateral mass screws and 13 pedicle screws) and occipital screws (50 screws) appeared satisfactory. No neurovascular damage occurred in all the patients. CONCLUSIONS Ninety eight percent of the screws were placed in ideal position with the aid of ICT. Only 2% of the screws deviated from the planned position, but the breaches were not clinically significant and hence no revision was required. This showed that ICT guidance can help to achieve a high accuracy of surgical instrumentation for the treatment of C1/C2 subluxation.
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Affiliation(s)
- Ji Min Ling
- Department of Neurosurgery, National Neuroscience Institute of Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
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