Hi, I'm talking to you today about intraoperative fluoroscopy and I want to thank the organizers to give me a chance to present this. Disclosures are not relevant for this. First before we go into fluoroscopic imaging, it's important to think about CRM positioning in DOR. Make sure you have a big enough room to accommodate for this. Depending on what kind of table you want to use, make sure it's radiolucent and far enough down so the CRM can move without getting obstructed. Foot rest needs to be put back so it doesn't block the way. And I have, as you can see here, the CRM slightly oblique so that the tower is not in the way, the pump and all the instrumentation we need. It also allows me to during surgery to rainbow at about 20 degrees so it doesn't obstruct my view or instrumentation as well. But here you see a postless system set up, which is what I usually use. And again, coming in oblique, making sure you have enough space. So this is what it looks like then, nicely draped and all that, you know, with with the Mayo stand in there, with the tower, the pump and everything out of the way. On the top left, you see an AP view, this is what I need for access. And then the other two show a slightly rainbow view 20 degrees. So I can use my instrumentation without hitting the CRM. So we need fluoroscopy for access and for resection. So here you see access imaging one for arthroscopic, so layer repair, rim trim, usually arthroscopy on the bottom. So with a guide wire. And then on the top you see for endoscopic abductor repair. So obviously slightly different space, but also with needles and wires. So for the endoscopic approach, also a P view and slight abduction of the hip. And before you get started and go to the OR, obviously you want to understand what you're looking at. So really important to understand the three dimensional bony anatomy. So there can be 3D CT imaging, help you understand what are you resecting, what are the goals here. And then you need different views intraoperatively where the fluoroscopy can help you to resect. Here is arthroscopic, a picture of the arthroscopic rim trimming before you see Laussen edge angle 46, afterwards down to 30. So fluoroscopy can help you understand, you know, where is the target, where are you resecting, and how much are you resecting so you're not over resecting. So very important. Also can be very helpful for us as a tablai to localize or even heterotopic ossification. Make sure you get to the target and be able to resect it and confirm that you have resected. So most importantly, in terms of what we're talking about here, would be for camera section. Again, as pointed out with the 3D CT scan imaging, it's a three-dimensional problem. So you cannot just look at one view, you need multiple views. And Chris Larson published a really nice paper, a reference further below, where the views are described and allow you to resect a typical camera deformity. So pre and post-operative checking. So the flowscopic imaging important to localize the problem but also confirm that you resected it. There's also intraoperative imaging software available to help you resect the adequate amount of CAM impingement. So it's real-time intraoperative alpha angle measurement. So you can make sure that you actually resect accurately in the right position. So it gives you an alpha angle before and after, can be very helpful and keeps you honest in terms of doing a routine every time the same way. And this is basically also incorporating some of the same views as described by Chris Larson. I add two more views. So Chris Larson had typically six, I added two, which is views on rainbow. Again, helping me to not hit the CRM here while I'm doing the resection. Technical pearls, it's always important to not just go by the numbers. Obviously you need to understand the pathology you're looking at. But if you have the intraoperative availability to measure the alpha angle. But it's also really important to individualize it per patient, so dynamic examination, take the hip throughout a range of motion, understand where might it be impinging. And sometimes you don't really pick up on that on the fluoroscopic imaging even. So I typically start in flexion, so I don't oversect proximally. So slight flexion, 20 to 30 degrees. I start my resection there under fluoroscopic confirmation. And then at the end go to full extension. So I don't want to have a steep step off. So once I'm in full extension, I can still resect and smoothen the transition without oversecting proximally. So in the wise words of Dr. Philippon, blue slope, not a black slope, based on skiing. So bottom left, that's not really a good resection. You want to have what's on the right, a nice smooth transition. So also more technical pearls, be consistent, have a routine use, views available, six or more depending on what you want. So have a system, be consistent. If you see a CAM on pelvis AP, you know it's going to be bigger, so probably take more time. So book longer OR time. So you're not, especially when you're getting started, so you're not stressed, just take your time, make sure you visualize everything. And the ones you see on AP views are typically bigger. And once you have those, I typically also, when I see them pelvis AP, I typically get a CT scan as well, just to really understand the full extent of this three-dimensionally. Some of the CAM deform is very large, you might not be able to get to all of it arthroscopically. So then you want to think about a surgical hip dislocation potentially. If you don't see progress in fluoroscopy, don't keep resecting because you might be over resecting. So change the rotation, typically go a more external rotation, make sure you see where you're working and not just blindly resecting and then over resecting. And here again is a paper, there's a series of paper by Chris Larson about the proper resection under fluoroscopic imaging. So this is one of them had nice imaging as well to show you where the resection and the fluoroscopic imaging lines up with the clock face. So here's a case of mine, this was a 20-year-old hockey goalie, college athlete. So you can see a large CAM deformity views and here intraoperative, again, being able to look real time while you're doing the surgery and you can document pre and post resection. So it helps you identify the problem, keep you real, make sure you resect everything, but also a nice tool afterwards to print out to show there's a patient. So a little close up view, so again, before and after, this is what it looked like. So again, fluoroscopic imaging, super important for access, but also resection. That is obviously CAM resection, pincer resection. Also when you're working on the ischiofemoral space and removing the lesser trochanter, so that can be important there to monitor your progress. Again, three-dimensional problems we deal with, so intraoperative fluoroscopy can help identify the problem. Thank you very much.

intraoperative fluoroscopy

C-arm positioning

three-dimensional bone anatomy

accurate resection

intraoperative imaging software