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Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration is increasingly used as a minimally invasive procedure in clinical settings. It is generally regarded as a safe procedure with high diagnostic accuracy. However, a complication involving a needle fracture that penetrated a nearby artery has not been reported during this procedure. Case Presentation: A male patient, 58 years of age, underwent endobronchial ultrasound-guided transbronchial needle aspiration for a mediastinal lymph node biopsy at a local hospital. The aspiration needle fractured and penetrated from the right middle segmental bronchus into the right pulmonary artery. The patient was then transferred to our hospital. After conducting repeated chest imaging examinations to confirm the presence of the foreign body and holding multidisciplinary team consultations, we first inserted a deflated balloon catheter near the puncture site in the right middle segmental bronchus. Following the needle retrieval through a flexible bronchoscope, the balloon catheter was inflated to ensure local hemostasis. Follow-up evaluations revealed no further complications for this patient. Conclusion: Intragenic vascular injury can occur during endobronchial ultrasound-guided transbronchial needle aspiration. Careful pre-procedure preparations should be planned to minimize complications. In patients experiencing complications due to needle penetration, consultation and coordination with a multidisciplinary team are essential to ensure the safe retrieval of the broken needle.

Iatrogenic retained foreign bodies can occur even after minimally invasive procedures like liposuction or dental interventions. Persistent or unexplained cutaneous symptoms should raise clinical suspicion. Early imaging and prompt removal are crucial to prevent complications and ensure patient safety.

Background Foreign bodies may be embedded or left behind in the oral cavity during oral surgical procedure. The loss of instruments such as impression material, surgical gauze, and broken injection needles are commonly reported in the dental field. These complications are generally symptomatic and show signs of inflammation, pain, and purulent discharge. Accidental breakage of suture needles is a rare but potentially dangerous event. Case presentation In this report, we present one case of lost suture needle during the procedure of flap operation at local dental clinic and its successful removal under local/general anesthesia administration via CBCT with a help of two reference needles to localize the 6-0 nylon needle and consulting with the clinician. Conclusion CT scanning taken while mouth-closing may not be accurate with regard to real location measurement performed while mouth-opening. If so, other up-to-date radiographic devices and methods to retrieve a needle are recommended.

Background Distal Phalanx (DP) fractures are the most common hand injuries. Bone fixation associated with soft tissue reconstruction, is often required to ensure more effective outcomes. The aim of the present study is to compare functional outcomes of DP fractures surgically treated with crossed manual drilled 23 Gauge needles vs crossed Kirschner-wires (k-wire). Methods Clinical data included analysis of patient demographics, range of motion (ROM), and complications. Radiographic assessment considered fracture type, location, fracture displacement, and radiographic union. Functional outcomes analysis was performed.The statistical significance was assessed at the level of probability lower than 5%. Results A total of 60 patients from 2012 to 2015 were retrospectively enrolled and among them 12 patients suffering from diabetes or current smokers. A total of 60 DP fractures were treated, 32 with needles (group A) and 28 with k-wire fixation (group B). Time to union, showed in different time points, was significantly lower in group A (≤ 40 days, p  = 0.023*) compared to group B. ROM of the distal interphalangeal joint at six months follow-up was 60° in group A and 40° in group B. A significant improvement was observed ( p  = 0.001*) in the 23 G needle treated group. Functional outcome analysis showed that VAS was significantly lower in group A compared to group B ( p  = 0.023*). Conclusion Our study showed that the 23 G needle yielded satisfactory results in terms of time to union and range of motion compared to k-wire fixation especially for tuft and shaft DP fractures. Therefore, should be a valid alternative to k-wire fixation in selected patients.

PurposeTo clarify the accuracy of vertebral puncture of the vertebral tertile area needling (VETERAN) method puncturing the pedicle superimposed on one-third of the width between the lateral vertebral line to the contralateral medial lamina line compared with Cathelin-needle-assisted puncture (CAP) method puncturing using the Cathelin needle as a guide in percutaneous vertebroplasty.Materials and methods449 punctures by CAP method and 125 punctures by VETERAN method were enrolled. We compared the puncture accuracy of both methods. We estimated a vertebral estimated tilting ratio (VET-ratio) defined as ratio of the distance between the lateral vertebral line and the contralateral medial laminal line to the distance between the vertebral lateral line and the puncture point measured by computed tomography. We also estimated the procedural items and clinical outcomes.ResultsVETERAN method with 100% of punctures within safe zone (cortical breaches within 2 mm) had significantly higher accuracy than CAP method with 97.8% (p < 0.01) for the 2 mm incremental evaluation. No cases with a VET-ratio of 36% or less had cortical breaches. VETERAN method had shorter operative time per puncture (p < 0.01) and exposure time per puncture (p < 0.05).ConclusionVETERAN method reduced the occurrence of the inaccurate puncture, operative times, and exposure times. A VET-ratio with 36% or less is associated with a safe puncture using VETERAN method.

Autoinjector devices are rapidly becoming the preferred method of drug delivery for a wide array of pharmaceuticals such as monoclonal antibodies. Yet, our understanding of injection biomechanics is limited, but is crucially important to create autoinjectors that lead to the least amount of pain, penetrate the skin to a desired depth, produce small lesions that minimize back flow of drug, and operate robustly even given the variability in the skin mechanics among individuals. We propose a finite element model of needle insertion coupled to the dynamic model of an autoinjector. The finite element model is embedded with a cohesive zone plane to capture crack initiation and propagation within an energy-based fracture mechanics framework. The cohesive zone model is supported by experimental observations of a mode I crack during the needle insertion into the soft tissue. Model calibration against force curves from needle insertion experiments leads to estimated material and fracture properties that match values reported in independent experiments from the literature. With the calibrated model we explore the effect of change in the material properties and device parameters on the insertion dynamics. One of the most interesting findings is that pre-compression of skin from the autoinjector base plate can regulate the stress field near the skin surface and add strain energy that is available for crack formation.

Background The prognosis of conservative treatment for fragility fracture of the pelvis (FFP) in the older patients remains poor. Percutaneous pelvic screw placement (PPSP), which aids in the treatment of FFP, can be challenging to perform using fluoroscopy alone because of the proximity of blood vessels and neuroforamina. Hence, this study aimed to investigate the accuracy and clinical outcomes of PPSP using real-time 3D fluoroscopic navigation for FFP in the hybrid operating room. Methods This study included 41 patients with FFP who underwent PPSP in a hybrid operating room between April 2016 and December 2020. Intraoperative C-arm cone-beam CT was performed under general anesthesia. Guidewire trajectory was planned using a needle guidance system. The guidewire was inserted along the overlaid trajectory using 3D fluoroscopic navigation, and a 6.5 mm cannulated cancellous screw (CCS) was placed. The clinical outcomes and accuracy of the screw placement were then investigated. Results A total of 121 screws were placed. The mean operative time was 84 ± 38.7 minutes, and the mean blood loss was 7.6 ± 3.8 g. The mean time to wheelchair transfer was 2 days postoperatively. Pain was relieved in 35 patients. Gait ability from preoperative and latest follow-up after surgery was maintained in 30 (73%) patients. All 41 patients achieved bone union. Of the 121 screws, 119 were grade 0 with no misplacement; only 2 patients had grade 1 perforations. Conclusion PPSP using real-time 3D fluoroscopic navigation in a hybrid operating room was accurate and useful for early mobilization and pain relief among older patients with FFP with an already-installed needle biopsy application.

Purpose Percutaneous fracture fixation involves multiple X-ray acquisitions to determine adequate tool trajectories in bony anatomy. In order to reduce time spent adjusting the X-ray imager’s gantry, avoid excess acquisitions, and anticipate inadequate trajectories before penetrating bone, we propose an autonomous system for intra-operative feedback that combines robotic X-ray imaging and machine learning for automated image acquisition and interpretation, respectively. Methods Our approach reconstructs an appropriate trajectory in a two-image sequence, where the optimal second viewpoint is determined based on analysis of the first image. A deep neural network is responsible for detecting the tool and corridor, here a K-wire and the superior pubic ramus, respectively, in these radiographs. The reconstructed corridor and K-wire pose are compared to determine likelihood of cortical breach, and both are visualized for the clinician in a mixed reality environment that is spatially registered to the patient and delivered by an optical see-through head-mounted display. Results We assess the upper bounds on system performance through in silico evaluation across 11 CTs with fractures present, in which the corridor and K-wire are adequately reconstructed. In post hoc analysis of radiographs across 3 cadaveric specimens, our system determines the appropriate trajectory to within 2.8 ± 1.3 mm and 2.7 ± 1.8 ∘ . Conclusion An expert user study with an anthropomorphic phantom demonstrates how our autonomous, integrated system requires fewer images and lower movement to guide and confirm adequate placement compared to current clinical practice. Code and data are available.

Background and AimsA freely available visual guide with optimal angles for paramedian approaches, depending on the skin-dural sac distance (S-DS-d) (http://diposit.ub.edu/dspace/handle/2445/179594 ) and viable paths for needle insertions perpendicular to the back, below the upper spinous process in a given interspinous space, had been described. Our aim was to verify needle location applying the guide in ex-vivo samples.MethodsRandom selection of ex-vivo samples with flexed lumbosacral spines (n=7), determination of S-DS-d in the interspinous spaces by ultrasound, needle insertions at axial 0°, below the upper spinous process at different interspinous spaces, from L4-L5 to L1-L2 [n=42; median (n=21), 1cm paramedian (n=16) or individualized paramedian, previsualizing the longest interlaminar height, pre-estimating the angle by means of a protractor (n=5)], computed tomography, three-dimensional reconstruction and verification of needle location (figure 1).Abstract EP243 Figure 13D reconstruction of bone structures and needle positions in flexed spines of ex-vivo samplesAbstract EP243 Figure 2When osteoporotic vertebral compression fractures are present, the contact between adjacent spinal processes impedes the needle penetration in median approachesAbstract EP243 Figure 3Median and paramedian approaches at 0° regarding the axial plane, taking the upper spinous process as reference, lead to successful needle insertions within the spinal canal in non-fractured spinesResultsWhen osteoporotic compression fracture was found (38%), the contact between adjacent spinous process impeded the median approach (figure 2), but most needle insertions were located within the spinal canal in the other cases (85.7% median or 81% 1cm paramedian) (figure 3). In 23% the needle remained within the canal beside the dural sac. In 13% a certain bone penetration occurred. Individualization of the paramedian approach led to successful insertions at very variable angles and distances (up to 32,2° and 2,64 cm paramedian, respectively).ConclusionsUltrasound may indicate if the interspinous space is visible. Then, the insertion of needles at 0° regarding the axial plane, taking the upper process as reference, is viable. If not, the alternative optimal paramedian approach must be individualized in fractured or rotated spines.