Periarticular screws: what’s in and what’s out of the joint?

Periarticular hardware placement can be challenging and a source of angst for orthopaedic surgeons due to fear of penetrating the articular surface and causing undue harm to the joint. In recent years, many surgeons have turned to computed tomography (CT) and other intraoperative or postoperative modalities to determine whether hardware is truly extraarticular in areas of complex anatomy. Yet, these adjuncts are expensive, time consuming, and often unnecessary given the advancement in understanding of intraoperative fluoroscopy. We present a review article with the goal of empowering surgeons to leave the operating room, with fluoroscopy alone, assured that all hardware is beneath the articular surface that is being worked on. By understanding a simple concept, surgeons can extrapolate the information in this article to any joint and bony surface in the body. While targeted at both residents and surgeons who may not have completed a trauma fellowship, this review can benefit all orthopaedic surgeons alike.

Intraoperative Fluoroscopy-Assisted Localization of Small Bowel Gastrointestinal Bleeding

Intraoperative management of refractory small bowel gastrointestinal bleeding continues to present challenges to surgeons, specifically, in localizing the source of bleeding. The need for operative intervention has decreased significantly with improved percutaneous radiologic techniques for embolization with good success rates. When percutaneous treatment methods fail, the surgeon is left with a variety of suboptimal options for localization if the pathologic source is not obvious on external inspection of the small bowel. This report describes a novel method for localizing small bowel gastrointestinal bleeding in those patients who have had previous coil embolization attempts at controlling small bowel gastrointestinal bleeding.

Clinical Application of a 3D-Printed Positioning Module and Navigation Template for Percutaneous Vertebroplasty

Background This study aimed to evaluate a personalized 3D-printed percutaneous vertebroplasty positioning module and navigation template based on preoperative CT scan data that was designed to treat patients with vertebral compression fractures caused by osteoporosis. Methods A total of 22 patients with vertebral compression fractures admitted to our hospital were included in the study. Positioning was performed with the new 3D-printed positioning module, and the navigation template was used for patients in the experimental group, and the traditional perspective method was used for patients in the control group. The experimental group consisted of 11 patients, 2 males and 9 females, with a mean age of 67.27 ± 11.86 years (range: 48 to 80 years), and the control group consisted of 11 patients, 3 males and 8 females, with a mean age of 74.27 ± 7.24 years (range: 63 to 89 years). The puncture positioning duration, number of intraoperative fluoroscopy sessions, and preoperative and postoperative visual analog scale (VAS) scores were statistically analyzed in both groups. Results The experimental group had shorter puncture positioning durations and fewer intraoperative fluoroscopy sessions than the control group, and the differences were statistically significant (P < .05). There were no significant differences in age or preoperative or postoperative VAS scores between the two groups (P > .05). Conclusions The new 3D-printed vertebroplasty positioning module and navigation template shortened the operation time and reduced the number of intraoperative fluoroscopy sessions. It also reduced the difficulty in performing percutaneous vertebroplasty and influenced the learning curve of senior doctors learning this operation to a certain degree.

Patient-Matched 3-D-Printed Guides for the Insertion of Cervical Pedicle Screws in Tumor Surgery

Background. Pedicle screw fixation in the cervical spine provides biomechanical advantages compared to other stabilization techniques. However, pedicle screw insertion in this area is challenging due to the anatomical conditions with a high risk of breaching the small pedicles and violating the vertebral artery or neural structures. Today, several techniques to facilitate screw insertion and to make the procedure safer are used. 3-D-printed patient-matched guides based on a CT reconstruction are a helpful technique which allows to reduce operation time and to improve the safety of pedicle screw insertion at the cervical spine. Cases. 3-D-printed patient-matched drill guides based on a CT scan with a 3-D reconstruction of the spine were used in two challenging cervical spine surgical tumor cases to facilitate the implantation of the pedicle screws. The screw position was controlled postoperatively by means of the routinely performed CT scan. Results. Postoperative imaging (conventional radiographs and CT scan) revealed the correct position of the pedicle screws. The time needed for screw insertion was short, and the need for intraoperative fluoroscopy could be reduced. There was no intra- or postoperative complication related to the pedicle screw implantation. Both tumors could be removed completely. Conclusion. These preliminary results show that 3-D-printed patient-specific guides are a promising tool to support and facilitate the implantation of cervical pedicle screws. The time needed for insertion is short, and intraoperative fluoroscopy time can be reduced. This technique allows for both a meticulous preoperative planning and a correct and therefore safe intraoperative positioning of cervical spine pedicle screws.

Operation Field Contamination During Intraoperative Fluoroscopy

Background: intraoperative C-arm fluoroscopy is commonly performed during traumatic orthopedic surgeries. The C-arm sterile drape is often used in cases of contamination of the operative field following postoperative infection. The aim of the present study was to investigate operation field contamination during traumatic orthopedic surgeries and evaluate the factors, especially intraoperative fluoroscopy, which affect operation field contamination. Methods: sterile 5% sheep blood Columbia agar plates were used to simulate the operation field. The C-arm was moved over the operation field in different grade clean operating rooms, simulating intraoperative fluoroscopy. The agar plates were then incubated and assessed for bacterial colony growth. Results: our results showed significant differences between the 3rd grade clean operating room and the 2nd or 1st grade clean operating rooms in the risk of operation field contamination. Nevertheless, there were no significant differences in the operation field contamination between the C-arm drape group and the control group. Conclusions: we conclude that C-arm equipment can be used without the drape during orthopedic surgeries to avoid contact with the operation field.

Treatment of humeral shaft fractures: a new minimally-invasive plate osteosynthesis versus open reduction and internal fixation: a case control study

Background To evaluate the feasibility and safety of a new minimally-invasive surgical approach–anteromedial minimally-invasive plate osteosynthesis (MIPO)–in the treatment of middle and distal humeral shaft fractures. Methods Fourteen patients with humeral shaft fracture treated with anteromedial MIPO from November 2016 to March 2020 (MIPO Group) were selected as the study subjects. Open reduction and internal fixation (ORIF) were used to treat 14 patients with humeral shaft fractures as the control group (ORIF group). The two groups were fixed with a locking compression plate (LCP) or LCP + multi-directional locking screw system (MDLS). The incision length, intraoperative blood loss, intraoperative fluoroscopy time, operation time, length of hospital stay, fracture healing time, QuickDASH score and Constant score were observed and compared between the two groups. Results Fourteen patients were enrolled in each group. The incision length (7.79 ± 2.39 cm), intraoperative blood loss (96.07 ± 14.96 mL), operative time (110.57 ± 21.90 min), hospital stay (6.29 ± 1.49 days) and fracture healing time (14.94 ± 0.99 weeks) in the MIPO group were all lower than those in the ORIF group, and the difference was statistically significant for each parameter (P < 0.05). The intraoperative fluoroscopy time (20.07 ± 3.22) in the MIPO group was significantly higher than that in the ORIF group (P < 0.05). There were no significant differences in age (P = 0.078), QuickDASH score (P = 0.074) or Constant score (P = 0.293) between the two groups and no postoperative complications occurred in any of the patients. Conclusion The anteromedial approach MIPO technique has the advantages of less trauma, less bleeding, low risk of nerve injury and high rate of fracture healing. It is one of the most effective methods for the treatment of middle and middle–distal humeral shaft fractures.