Radiation exposure using the O-arm<Superscript>®</Superscript> surgical imaging system

Purpose

This study was conducted to characterise the O-arm^® surgical imaging system in terms of patient organ doses and medical staff occupational exposure during three-dimensional thoracic spine and pelvic examinations.

Methods

An anthropomorphic phantom was used to evaluate absorbed organ doses during a three-dimensional thoracic spine scan and a three-dimensional pelvic scan with the O-arm^®. Staff occupational exposure was evaluated by constructing an ambient dose cartography of the operating theatre during a three-dimensional pelvic scan as well as using an anthropomorphic phantom to simulate the O-arm^® operator.

Results

Patient organ doses ranged from 30 ± 4 μGy to 20.0 ± 3.0 mGy and 4 ± 1 μGy to 6.7 ± 1.0 mGy for a three-dimensional thoracic spine and pelvic examination, respectively. For a single three-dimensional acquisition, the maximum ambient equivalent dose at 2 m from the iso-centre was 11 ± 1 μSv.

Conclusion

Doses delivered to the patient during a three-dimensional thoracic spine image acquisition were found to be significant with the O-arm^®, but lower than those observed with a standard computed tomography examination. The detailed dose cartography allows for the optimisation of medical staff positioning within the operating theatre while imaging with the O-arm^®.

     

Intraoperative radiation exposure in spinal scoliosis surgery for pediatric patients using the O-arm<Superscript>®</Superscript> imaging system

Purpose

The O-arm^® navigation system allows intraoperative CT imaging that can facilitate highly accurate instrumentation surgery, but radiation exposure is higher than with X-ray radiography. This is a particular concern in pediatric surgery. The purpose of this study is to examine intraoperative radiation exposure in pediatric spinal scoliosis surgery using O-arm.

Methods

The subjects were 38 consecutive patients (mean age 12.9 years, range 10–17) with scoliosis who underwent spinal surgery with posterior instrumentation using O-arm. The mean number of fused vertebral levels was 11.0 (6–15). O-arm was performed before and after screw insertion, using an original protocol for the cervical, thoracic, and lumbar spine doses.

Results

The average scanning range was 6.9 (5–9) intervertebral levels per scan, with 2–7 scans per patient (mean 4.0 scans). Using O-arm, the dose per scan was 92.5 (44–130) mGy, and the mean total dose was 401 (170–826) mGy. This dose was 80.2% of the mean preoperative CT dose of 460 (231–736) mGy (P = 0.11). The total exposure dose and number of scans using intraoperative O-arm correlated strongly and significantly with the number of fused levels; however, there was no correlation with the patient’s height.

Conclusions

As the fused range became wider, several scans were required for O-arm, and the total radiation exposure became roughly the same as that in preoperative CT. Use of O-arm in our original protocol can contribute to reduction in radiation exposure.

     

Short-term outcomes of arthroscopic TightRope<Superscript>®</Superscript> fixation are better than hook plate fixation in acute unstable acromioclavicular joint dislocations

Aim

The aim of this study was to compare the short-term outcomes of arthroscopic TightRope^® fixation with that of hook plate fixation in patients with acute unstable acromioclavicular joint dislocations.

Patients and methods

We conducted a prospective case–control study of twenty-six patients with an acute ACJ dislocation who underwent surgical repair with either an arthroscopic TightRope^® fixation or a hook plate from 2013 to 2016. Clinical and radiological data were collected prospectively. Clinical outcomes were evaluated using the Constant Score, the University of California at Los Angeles (UCLA) Shoulder Score, Oxford Shoulder Score as well as the visual analogue scale. Radiological outcomes were assessed with the coracoclavicular distance (CCD).

Results

Sixteen patients underwent arthroscopic TightRope^® fixation, while 10 patients underwent hook plate fixation. There were no significant differences in the preoperative variables except for the mean UCLA 4b infraspinatus score (TightRope^® 2.8 vs. hook plate 3.8; p = 0.030). Duration of surgery was significantly longer in the TightRope^® group. At 1 year post-operatively, the TightRope^® group had a significantly better Constant Score and CCD with no complications. All patients with hook plate fixation had to undergo a second procedure for removal of implant, and 3 patients had complications.

Conclusions

Arthroscopic TightRope^® fixation is a good option for the treatment of acute unstable ACJ dislocations. It has better short-term clinical and radiological outcomes as well as lesser complications when compared to hook plate fixation.

Level of evidence

Therapeutic, Level III.

     

Off-pump hemostasis for left ventricular rupture after myocardial infarction with Hydrofit<Superscript>®</Superscript> and Surgicel<Superscript>®</Superscript>

Left ventricular free wall rupture (LVFWR) is a catastrophic complication of myocardial infarction. In these cases, cardiopulmonary bypass (CPB) should be performed for left ventricular repair, but can impact hemodynamic stability. An 87-year-old man presented with acute shock. He was diagnosed with LVFWR after myocardial infarction. We describe a simple, effective, and reproducible technique to achieve hemostasis at the LVFWR site during emergency operation using Hydrofit^® and Surgicel^® surgical hemostatic agents. We simply placed and manually pressed the Hydrofit^® and Surgicel^® composite on the bleeding site. This technique provides complete hemostasis without CPB establishment.     

Repositioning the Lap-Band<Superscript>®</Superscript> for Proximal Pouch Dilatation

Background: Laparoscopic adjustable gastric banding (LAGB) procedures have proved their efficiency and reproducibility in several studies. The most frequent late complication is proximal pouch dilatation, with possible progression to total food intolerance. Materials and Methods: In a series of 727 laparoscopic bandings using the Lap-Band^? System, 54 patients presented proximal pouch dilatation and required laparoscopic reposition of the band. 2 patients who had had LAGB placed in another hospital received the same treatment. Results: No particular intra- or postoperative complications occurred during laparoscopic repositioning of the band. 2 conversions were necessary in the beginning of the experience to safely unlock the band. After a median follow-up of 74 months, there has been no recurrence of proximal dilatation. Conclusions: Laparoscopic repositioning of the Lap-Band^? System for proximal pouch dilatation is a safe and reproducible procedure which can be proposed as an interesting alternative to its replacement by a new one. An initial perigastric placement of the band allows, during the redo, safe dissection in a virgin pars flaccida tunnel. The calibration of the tiny proximal pouch, the presence of postoperative adhesions, and maintainance of strict control of dietary behavior are probably the reasons for the absence of recurrence of pouch dilatation.     

Codification of Techniques for Reoperation After Lap-Band<Superscript>®</Superscript>

Background: The Lap-Band^? is a safe, reversible, minimally invasive, and effective bariatric technique, whose main late complications are herniation/dilation of the pouch, erosion/migration of the band, and problems with the adjustment system (subcutaneous access port and connection tubing). We describe the surgical timing and techniques for dealing with the principal complications. Methods: Between October 1995 and September 2001, we treated 540 patients (mean age 43 years, mean BMI 42.6 kg/m²). All operations were completed laparoscopically, with no intra-operative complications or mortality. Late complications were: problems with the band adjustment system (n=35); herniation/dilations of the pouch (n=14); erosions/migration of the band into the stomach (n=3). Results: We dealt successfully with all complications using a minimally invasive technique. Herniation/dilations of the pouch necessitated 15 successful repositionings of the band, and 2 removals of the band at the patients' request. Erosion/migration was treated by endo-laparoscopic band removal. Problems with the band adjustment system had to be corrected laparoscopically, under general anesthesia in 17 patients. Conclusion: While emphasizing the rarity of complications, we have codified re-operation techniques to help Lap-Band^? users solve them using a minimally invasive procedure. In particular, problems with the port and connection tubing system can be completely avoided with a transverse subcutaneous positioning in a straight line.     

Emergency iliosacral screw fixation assisted by TiRobot for unstable posterior pelvic ring fracture北大核心CSCD

Objective To evaluate the emergency iliosacral screw fixation assisted by TiRobot for unstable posterior pelvic ring fracture. Methods The 26 patients with unstable pelvic fracture were analyzed retrospectively who had undergone emergency iliosacral screw fixation at Department of Orthopedics & Traumatology, Beijing Jishuitan Hospital from June 2018 to December 2020. They were divided into 2 groups depending on whether orthopaedic TiRobot was used to assist screw insertion. In the observation group of 14 cases subjected to TiRobot-assisted insertion of iliosacral screws, there were 10 males and 4 females with an age of (45.9 ± 10.1) years; in the control group of 12 cases subjected to conventional manual insertion of iliosacral screws, there were 9 males and 3 females with an age of (49.2 ± 11.3) years. All the surgeries were conducted within 24 hours after injury. The 2 groups were compared in terms of screw insertion time, pin insertion, intraoperative blood loss, fluoroscopy time, postoperative screw position, fracture reduction and Harris hip score at the final follow-up. Results The 2 groups were comparable because there was no significant difference between them in their preoperative general clinical data or follow-up time (P>0.05). The screw insertion time [(16.1 ± 3.4) min] and fluoroscopy time [(8.1 ± 3.3) s] in the observation group were significantly shorter than those in the control group [(26.4 ± 5.4) min and (25.2 ± 7.4) s], and the pin insertions [1 (1, 2) times] and intraoperative blood loss [(10.5 ± 6.4) mL] in the former were significantly less than those in the latter [6 (3, 8) times and (24.8 ± 6.7) mL] (all P<0.05). Postoperatively, the sacroiliac screw position was excellent in 18 cases and good in 2 in the observation group while excellent in 14 cases, good in 2 and poor in 2 in the control group; the fracture reduction was excellent in 12 cases, good in one and fair in one in the observation group while excellent in 10 cases, good in one and fair in one in the control group, showing insignificant differences in the above comparisons (P>0.05). There was no significant difference either in the Harris hip score at the final follow-up between the 2 groups (P>0.05). Conclusion Compared with conventional manual insertion of iliosacral screws, emergency iliosacral screw fixation assisted by TiRobot can effectively decrease surgical time and reduce operative invasion due to a higher accuracy rate of screw insertion. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

Anterior fixation of unstable pelvic ring fractures using the modified Stoppa approach: mid-term results are independent on patients’ age

Purpose

Open surgical management of unstable pelvic ring injuries has been discussed controversially compared to percutaneous techniques in terms of surgical site morbidity especially in older patients. Thus, we assessed the impact of age on the outcome following fixation of unstable pelvic ring injuries through the modified Stoppa approach.

Methods

Out of a consecutive series of 92 patients eligible for the study, 63 patients (mean age 50 years, range 19–78) were evaluated [accuracy of reduction, complications, failures, Majeed-Score, Oswestry Disability Questionnaire (ODI), Mainz Pain Staging System (MPSS)] at a mean follow-up of 3.3 years (range 1.0–7.9). Logistic multivariate regression analysis was performed to assess the outcome in relation to increasing patient age and/or Injury Severity Score (ISS).

Results

Out of 63 patients, in 36 an “anatomic” reduction was achieved. Ten postoperative complications occurred in eight patients. In five patients, failure of fixation was noted at the anterior and/or posterior pelvic ring. In 49 patients, an “excellent” or “good” Majeed-Score was obtained; the mean ODI was 14 % (range 0–76 %); 50 patients reported either no or only minor chronic pelvic pain (MPSS). Only an increasing ISS conferred an increased likelihood of the occurrence of a non-anatomical reduction, a “poor” or “fair” Majeed-Score, or an ODI >20 %.

Conclusions

Increasing age did not impact the analysed parameters. Open reduction and internal fixation of the anterior pelvic ring through a modified Stoppa approach in unstable pelvic ring injuries did not result in an unfavourable outcome with increasing age of patients.

     

Laparoscopic Management of Lap-Band<Superscript>®</Superscript> Slippage

Background. The Lap-Band^? is generally associated with a low morbidity rate. Although gastric slippage through the band remains a concern, the rate has diminished with new band placement techniques. Methods. Between November 2000 and June 2002, 198 Lap-Band? Systems were inserted in patients in the Houston, Texas, area. 4 of these patients, plus an additional patient whose Lap-Band^? had been inserted by another surgeon, developed slippages, and in each case the gastric slip was corrected and the band was salvaged and repositioned laparoscopically. To facilitate dissection and repositioning of the band in 3 of these patients, the band had to be unlocked using a simple laparoscopic technique. Results. All patients were discharged the morning following surgery with no complications and good position of the band as evidenced by esophagogram study and resolution of symptoms. After 2 to 12 months follow-up, all 5 patients remain symptom-free and continue to lose weight. Conclusions. Gastric slippage with the Lap-Band^? can be managed by laparoscopic salvage and repositioning of the slipped band.     

Stiffness measurement of the neocallus with the Fraktometer FM 100<Superscript>®</Superscript>

Introduction: The assessment of fracture healing is subjective, and neither radiology nor manual examination allows a reliable determination of bone healing. Fracture healing control in the treatment of tibia shaft fracture with external fixator by a stiffness measurement system (Fraktometer FM 100^®) is known from clinical studies. The purpose of this study was to follow stiffness control at external fixator in healing of callotasis with the stiffness measurement system. Materials and methods: From 1994 to 1997 stiffness measurements with the described system (Fraktometer FM 100) were performed in the BG-Clinic Ludwigshafen to assess the healing course in 11 cases of callotasis at lower limb. Results: In ten cases, regular healing could be followed by signal decrease; in one case, a persistent signal without tendency to decrease was able to reveal callotasis failure at an early point of time. The investigation could also show the importance of bending stiffness control. One case of late axis deformation after fixator removal occurred because of disregarding delayed bending signal decrease. Conclusion: Measurements of the external fixator’s stiffness after callotasis can provide useful additional information for further treatment strategy.     

Locked nailing for the treatment of displaced articular fractures of the calcaneus: description of a new procedure with calcanail<Superscript>®</Superscript>

Although open reduction and internal fixation is considered the best method for treating displaced articular fractures of the calcaneus, lateral approach is at high risk for wound healing complications. For this reason, the authors developed a posterior approach and a new implant to perform both intrafocal reduction and internal fixation. The aim of this technical note is to describe this method of treatment for displaced articular fractures of the calcaneus, which offered the following advantages: (a) the creation of a working channel that provides also a significant bone autograft, (b) the intrafocal reduction of the displaced articular surface, (c) the insertion of a locking nail that maintains the reduced articular surface at the right height, (d) the possibility to switch from an ORIF to a reconstruction arthrodesis with the same approach and instrumentation in case of severely damaged posterior facet.     

Abdominal wall hernia repair: a comparison of Permacol<Superscript>®</Superscript> and Surgisis<Superscript>®</Superscript> grafts in a rat hernia model

Background

This study compared two porcine-derived grafts Permacol (Tissue Science Laboratory, Covington, GA, USA) and Surgisis (Cook Surgical, Bloomington, IN, USA) in terms of strength of incorporation (SOI), incorporation of host tissue, and adhesion formation using a rat model.

Methods

A prospective randomized study using 48 Sprague–Dawley rats. A standardized 1.5 × 5 cm fascial defect was created and repaired with either Permacol or Surgisis grafts. The rats were then sacrificed at 3, 14, 28, or 60 days. The specimens were examined for SOI, neovascularization, collagen deposition, collagen organization, and adhesion formation.

Results

Surgisis had significantly greater SOI than Permacol at 28 (0.115 vs. 0.0754 Mpa) and 60 days (0.131 vs. 0.635 Mpa). Surgisis had significantly more collagen deposition and neovascularization than Permacol at 60 days. The area of adhesions was not significantly different between Surgisis and Permacol.

Conclusion

Surgisis is superior to Permacol in terms of SOI and tissue ingrowth at 60 days. Furthermore, Surgisis strengthened over time whereas Permacol decreased in strength.

     

Efficacy of TiRobot-assisted minimally invasive percutaneous screw fixation for pelvic fractures北大核心CSCD

Objective To investigate the clinical efficacy of TiRobot-assisted minimally invasive percutaneous screw fixation for pelvic fractures. Methods The clinical data of 44 patients with pelvic fracture were retrospectively analyzed who had undergone TiRobot-assisted minimally invasive percutaneous screw fixation from May 2018 to April 2021 at Department of Orthopedic Traumatology, The First Hospital of Jilin University. There were 30 males and 14 females, aged from 11 to 78 years (average, 40. 6 years). According to the Tile classification, there were 20 type CI fractures, 23 type C2 fractures and one type C3 fracture. The time from injury to operation averaged 8. 2 days (from 1 to 41 days). The minimally invasive percutaneous screw fixation was assisted by the orthopaedic TiRobot in all patients. Operation time, fluoroscopy time, reduction quality, complications and functional recovery at the final follow-up were recorded and analyzed. Results A total of 96 screws were implanted in this cohort. The total fluoroscopy time ranged from 17 to 66 s, with an average of 17. 8 s for each single screw. The operation time ranged from 50 to 355 min, averaging 179. 7 min. According to the Matta criteria, the reduction quality was rated as excellent in 36 cases, as good in 5 and as fair in 3, yielding an excellent and good rate of 93. 2% (41/44). All the 44 patients were followed up for 6 to 42 months (average, 20. 4 months). The fracture healing time ranged from 2 to 6 months, averaging 3. 3 months. The Majeed scores at the final follow-up ranged from 51 to 100 points (average, 83. 7 points); there were 28 excellent, 8 good, 7 fair and one poor cases, giving an excellent to good rate of 81. 8% (36/44). Follow-up found no such complications as iatrogenic neurovascular injury, incision infection, malunion, implant loosening or fracture re-displacement in all the 44 patients. Conclusion TiRobot-assisted minimally invasive internal fixation can result in fine clinical efficacy for pelvic fractures, showing advantages of accuracy, minimal invasion and safety. © The Author(s) 2023.     

Die Bedeutung des Advanced Trauma Life Support<Superscript>®</Superscript> (ATLS<Superscript>®</Superscript>) im Schockraum

INTRODUCTION: There is clinical evidence, that a standardized management of trauma patients in the emergency room improves outcome. METHODS: The ATLS training course teaches a systematic approach to the trauma patient in the emergency room. The aim is a rapid and accurate assessment of the patient's physiologic status, the treatment according to priorities and the decision making if transfer to a trauma center is necessary. The German Trauma Society has taken over the course concept from the American College of Surgeons (ACS) and is authorized to organize ATLS courses in Germany. RESULTS: A standardized management in the emergency room helps to prevent secondary injury, to realize timing as a relevant factor in the initial treatment and to assure a high standard of care. The ATLS course provides the participant with knowledge, skills and attitudes and is open to doctors of all specialties involved in the initial management of severely injured patients. CONCLUSION: ATLS teaches a standardized and established approach to the trauma patient in the emergency room. It has been transferred to 46 countries and the content is reviewed regularly to consider new scientific evidence. Germany has the chance to participate in this international standard of care and to introduce own experiences into the review process.     

Addition of a video camera system improves the ease of Airtraq<Superscript>®</Superscript> tracheal intubation during chest compression

Recent resuscitation guidelines for cardiopulmonary resuscitation emphasize that rescuers should perform tracheal intubation with minimal interruption of chest compressions. We evaluated the use of video guidance to facilitate tracheal intubation with the Airtraq (ATQ) laryngoscope during chest compression. Eighteen novice physicians in our anesthesia department performed tracheal intubation on a manikin using the ATQ with a video camera system (ATQ-V) or with no video guidance (ATQ-N) during chest compression. All participants were able to intubate the manikin using the ATQ-N without chest compression, but five failed during chest compression (P < 0.05). In contrast, all participants successfully secured the airway with the ATQ-V, with or without chest compression. Concurrent chest compression increased the time required for intubation with the ATQ-N (without chest compression 14.8 ± 4.5 s; with chest compression, 28.2 ± 10.6 s; P < 0.05), but not with the ATQ-V (without chest compression, 15.9 ± 5.8 s; with chest compression, 17.3 ± 5.3 s; P > 0.05). The ATQ video camera system improves the ease of tracheal intubation during chest compressions.