Robotic-Assisted Bronchoscopy Integrated with Three-Dimensional Fluoroscopy for Sampling Bilateral Pulmonary Nodules in a Single Procedure

Bronchoscopic biopsy of peripheral pulmonary nodules has evolved in recent years with the emergence of new technologies such as shape-sensing robotic-assisted bronchoscopy. The use of three-dimensional (3D) fluoroscopy for intraoperative visualization of the biopsy tool in relation to the target nodule aims to overcome computed tomography-to-body divergence encountered during the procedure and allows for more accurate sampling to improve adequacy and diagnostic performance. Until recently, the robotic-assisted navigation plan and 3D imaging function as separate systems. We present a case where intraoperative 3D fluoroscopy images were integrated to the robotic bronchoscopy navigation system, resulting in a single, dynamic, real-time 3D virtual plan showing readjusted paths toward the lesion displayed in the robotic bronchoscopy navigation system, allowing in this case, biopsying two bilateral pulmonary nodules, resulting in different diagnosis within the same endoscopic procedure.

O-Arm Accuracy and Radiation Exposure in Adult Deformity Surgery

OBJECTIVE

In long thoracolumbar deformity surgery, accurate screw positioning is critical for spinal stability. We assessed pedicle and pelvic screw accuracy and radiation exposure in patients undergoing long thoracolumbar deformity fusion surgery (≥4 levels) involving 3-dimensional fluoroscopy (O-Arm/Stealth) navigation.

METHODS

In this retrospective single-center cohort study, all patients aged >18 years who underwent fusion in 2016-2018 were reviewed. O-Arm images were assessed for screw accuracy. Effective radiation doses were calculated. The primary outcome was pedicle screw accuracy (Heary grade). Secondary outcomes were pelvic fixation screw accuracy, radiation exposure, and screw-related perioperative and postoperative complications or revision surgery within 3 years.

RESULTS

Of 1477 pedicle screws placed in 91 patients (mean 16.41 ± 5.6 screws/patient), 1208 pedicle screws (81.8%) could be evaluated by 3-dimensional imaging after placement. Heary Grade I placement was achieved in 1150 screws (95.2%), Grade II in 47 (3.9%), Grade III in 10 (0.82%), Grade IV in 1 (0.08%), and Grade V in 0; Grade III-V were replaced intraoperatively. One of 60 (1.6%) sacroiliac screws placed showed medial cortical breach and was replaced. The average O-Arm-related effective dose was 29.54 ± 14.29 mSv and effective dose/spin was 8.25 ± 2.65 mSv. No postoperative neurological worsening, vascular injuries, or revision surgeries for screw misplacement were recorded.

CONCLUSIONS

With effective radiation doses similar to those in interventional neuroendovascular procedures, the use of O-Arm in multilevel complex deformity surgery resulted in high screw accuracy, no need for surgical revision because of screw malposition, less additional imaging, and no radiation exposure for the surgical team.

Use of the Hybrid Operating Room for Pelvic and Acetabular Fracture Surgery

The hybrid operating room (HOR) utilizes advanced imaging technology to improve intra-operative visualization and facilitate efficient care in procedures that are relatively image dependent. The robotic C-arm provides improved 2D image quality and is capable of large volume three-dimensional fluoroscopy (3DF) that can rapidly create multiplanar CT like images. Here we discuss on the technique, utility, potential benefits, pitfalls, and complications of using the hybrid suite with and without intra-arterial balloon occlusion for pelvic and acetabular fracture surgery. We also present a case series of patient who underwent pelvic fixation using the HOR. While not advocated for routine use in all pelvic and acetabular fractures; the hybrid suite can be an effective tool in the treatment of complex cases and may facilitate efficient care of the hemodynamically unstable patient. It should be considered when resuscitative stabilization, angioembolization, intra-arterial balloon occlusion, or life-threatening bleeding is anticipated. Additionally, use of the hybrid room allows access to 3D fluoroscopy, and the associated benefits, if a mobile 3D unit is otherwise unavailable. These benefits must be weighed against the cumbersome table, the potential pitfalls with patient size and positioning, and the increased cost to the hospital.

Patient-specific instrumentation improves functional kinematics of minimally-invasive total knee replacements as revealed by computerized 3D fluoroscopy

BACKGROUND AND OBJECTIVES

Minimally-invasive total knee arthroplasty (MIS-TKA) has demonstrated very good short-term success, but its mid- to long-term results remain inconclusive. The success may be related to the tradeoff between a small incision and accurate positioning of the implant components. Patient-specific instrumentation (PSI) aims to improve the accuracy in restoring the knee axis and the clinical outcomes for MIS-TKA, but the results are yet to be confirmed by accurate assessment during functional activities. The purpose of the current study was to measure and compare the in vivo three-dimensional (3D) rigid-body and surface kinematics of MIS-TKA implanted with and without PSI during isolated knee active flexion/extension and sit-to-stand using state-of-the-art 3D model-based fluoroscopy technology.

METHODS

Ten patients treated for advanced medial knee osteoarthritis by MIS-TKA without PSI (non-PSI group) and nine with PSI (PSI group) participated in the current study. Each subject performed non-weight-bearing knee flexion/extension and sit-to-stand tasks while the motion of the prosthetic knee was under bi-plane fluoroscopy surveillance. The computer models of each of the knee prosthesis components were registered to the measured fluoroscopy images for each time frame via a novel validated 3D fluoroscopy method. Non-parametric 1-tailed Mann-Whitney tests were performed to detect the differences in the joint and surface kinematic variables every 10° of knee flexion between the non-PSI and PSI groups. The 1-tailed significance level was at α = 0.05.

RESULTS

The PSI group showed clear, coupled flexion/internal rotation during activities, while the non-PSI group remained roughly at an externally rotated position with slight internal rotations. The coupled rotation in the PSI group was accompanied by an anterior displacement of the medial contact and a posterior displacement of the lateral contact, which was different from the screw-home mechanism. Neither of the two groups showed the normal roll-back phenomenon, i.e., posterior translation of the femur relative to the tibia during knee flexion.

CONCLUSIONS

With the state-of-the-art 3D fluoroscopy method, differences in both the rigid-body and surface kinematics of the prosthetic knees between MIS-TKA with and without PSI were identified. Patients with PSI demonstrated significant positive effects on the reconstructed rigid-body kinematics of the knee, showing clearer coupled flexion/internal rotations - an important kinematic characteristic in healthy knees - than those without PSI during activities with or without weight-bearing. However, none of them showed normal contact patterns. The current findings will be helpful for surgical instrument design, as well as for surgical decision-making in MIS total knee arthroplasty.