The Value of Intraoperative 3-Dimensional Fluoroscopy in the Treatment of Distal Radius Fractures: A Randomized Clinical Trial

On the use of intraoperative 3D-RX C-arm imaging in orthognathic surgery: a prospective non-consecutive case series study

CONTEXT

Segment and osteosynthesis malposition resulting in patients' complaints (mainly about asymmetries) are encountered in orthofacial/orthognathic surgery.

OBJECTIVE, DESIGN, AND SETTING

We planned to investigate the usefulness of intraoperative three-dimensional (3D) imaging concerning positioning and fixation of bone segments and osteosynthesis in orthognathic/orthofacial surgery. We performed a prospective study of non-consecutive cases. All patients receiving a bimaxillary osteotomy, genioplasty, and their combinations were included in the study from May 2016 to May 2020. Unilateral and bilateral sagittal split osteotomies were excluded. There were no gender and age limitations. All were intraoperatively examined using the BV Pulsera 3D-RX System (Philips Medical, Eindhoven, The Netherlands). The outcome variables were the percentage of revisions of segment positioning and osteosynthesis. Predictor variables were age, gender, type of surgery, timing (pre- and post-imaging), and surgeon experience (senior vs assistant).

RESULTS

Forty female and twenty-two male patients were included (mean age 25.25 years ± 7.52 and 29.1 years ± 12.6 respectively). We evaluated 27 genioplasties and 34 Le Fort "type-I" osteotomies. Indications for segment repositioning and redo-osteosynthesis increased after intraoperative imaging as compared to operator's clinical judgment before intraoperative imaging (95% confidence interval; p < .001 and p = .002 respectively).

CONCLUSION

Suboptimal positioning and fixation of bone segments or osteosynthesis were more apparent with 3D imaging. In addition, some satisfactory cases were also revised for an optimal outcome. As a result, surgeons were prompted to more revisions than judged necessary without intraoperative imaging.

"Spin" in Plastic Surgery Randomized Controlled Trials with Statistically Nonsignificant Primary Outcomes: A Systematic Review

BACKGROUND

"Spin" refers to a manipulation of language that implies benefit for an intervention when none may exist. Randomized controlled trials (RCTs) in other fields have been demonstrated to employ spin, which can mislead clinicians to use ineffective or unsafe interventions. This study's objective was to determine the strategies, severity, and extent of spin in plastic surgery RCTs with nonsignificant primary outcomes.

METHODS

A literature search of the top 15 plastic surgery journals using MEDLINE was performed (2000 through 2020). Parallel 1:1 RCTs with a clearly identified primary outcome showing statistically nonsignificant results ( P > 0.05) were included. Screening, data extraction, and spin analysis were performed by two independent reviewers. The spin analysis was then independently assessed in duplicate by two plastic surgery residents with graduate-level training in clinical epidemiology.

RESULTS

From 3497 studies identified, 92 RCTs were included in this study. Spin strategies were identified in 78 RCTs (85%), including 64 abstracts (70%) and 77 main texts (84%). Severity of spin was rated moderate or high in 43 abstract conclusions (47%) and 42 main text conclusions (46%). The most identified spin strategy in the abstract was claiming equivalence for statistically nonsignificant results (26%); in the main text, focusing on another objective (24%).

CONCLUSIONS

This study suggests that 85% of statistically nonsignificant RCTs in plastic surgery employ spin. Readers of plastic surgery research should be aware of strategies, whether intentional or unintentional, used to manipulate language in reports of statistically nonsignificant RCTs when applying research findings to clinical practice.

3D Reconstruction of Wrist Bones from C-Arm Fluoroscopy Using Planar Markers

In orthopedic surgeries, such as osteotomy and osteosynthesis, an intraoperative 3D reconstruction of the bone would enable surgeons to quickly assess the fracture reduction procedure with preoperative planning. Scanners equipped with such functionality are often more expensive than a conventional C-arm fluoroscopy device. Moreover, a C-arm fluoroscopy device is commonly available in many orthopedic facilities. Based on the widespread use of such equipment, this paper proposes a method to reconstruct the 3D structure of bone with a conventional C-arm fluoroscopy device. We focus on wrist bones as the target of reconstruction in this research as this will facilitate a flexible imaging scheme. Planar markers are attached to the target object and are tracked in the fluoroscopic image for C-arm pose estimation. The initial calibration of the device is conducted using a checkerboard pattern. In general, reconstruction algorithms are sensitive to geometric calibration errors. To assess the practicality of the method for reconstruction, a simulation study demonstrating the effect of checkerboard thickness and spherical marker size on reconstruction quality was conducted.

A Prospective Cohort Study on Accuracy of Dorsal Tangential Views to Avoid Screw Penetration With Volar Plating of Distal Radius Fractures

OBJECTIVE

To assess diagnostic performance of dorsal tangential views (DTVs) to detect dorsal screw protrusion in clinical practice.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Fifty consecutive patients undergoing volar plating for 50 distal radius fractures were prospectively included.

INTERVENTION

Fluoroscopic DTVs were routinely obtained, and screw revision was documented. Multiplanar reconstructions of postoperative CTs allowed for detection and quantification of dorsal screw penetration using reproducible measuring techniques.

MAIN OUTCOME MEASUREMENTS

Diagnostic performance (sensitivity, negative predictive value, positive predictive value, and accuracy) of DTV.

RESULTS

Intraoperatively, in 16 of 50 patients (32%), screws were revised based on DTV, with 13 of 218 screws (6.0%) being revised due to dorsal prominence. One screw was changed because DTV showed it was in the distal radioulnar joint. Postoperatively, in 10 patients (20%), the computed tomography revealed 12 additional screws penetrating ≥1 mm with an average of 1.8 mm (range 1.0-4.5 mm). DTV had a sensitivity of 52%, a negative predictive value of 95%, and accuracy of 95%. No ≥1-mm protruding screw remained in the third compartment.

CONCLUSIONS

In one-third of our patients, the incidence of protruding screws that can cause iatrogenic extensor tendon rupture was reduced by obtaining additional DTVs. Although DTV reduces the incidence of dorsal screw penetration considerably, this study reveals limited sensitivity. Therefore, one should keep in mind that dorsal screw penetration may go unnoticed on DTVs, and proper surgical technique remains paramount of DTV.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.