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Dorsal Screw Protrusion Identification Following Volar Plating for a Distal Radial Fracture: Comparing Skyline View Versus Intraoperative 3D Fluoroscopy
Jesse Jupiter, md, ma
harvard medical school, palm beach gardens, FL
HYPOTHESIS This study investigates the efficacy of intraoperative 3D fluoroscopy compared to skyline view for detecting dorsal cortex screw protrusion in volar locking plating (VLP) procedures for unstable distal radius intra-articular fractures (DRF). This is assessed through postoperative CT, addressing the limitations of previous methods in evaluating screw penetration accurately. METHODS The study utilized the ICUC database, a prospective cohort of patients with surgically treated DRF, to select cases with available imaging from skyline views, intraoperative 3D fluoroscopy, and postoperative CT scans. The evaluation included determining if screws were penetrated the dorsal cortex or not. Intraoperative 3D fluoroscopy's coronal, axial, and sagittal views identified dorsal screw protrusions, confirmed by postoperative CT. Cohen's Kappa was calculated using STATA 15.1 to assess the interrater reliability of intraoperative imaging compared to postoperative CT. RESULTS Twenty-two intra-articular DRFs were included in the study. The agreement between skyline view and postoperative CT was moderate agreement, with a kappa value of 0.493 (95% CI: 0.243 to 0.696, N=76), identifying three uncertain, 57 shorter screws and 16 screw penetrations. Intraoperative 3D fluoroscopy demonstrated almost perfect agreement with postoperative CT, with a kappa of 0.849 (95% CI: 0.705 to 0.992, N=76), identifying 58 shorter screws, 18 screw penetrations. The sensitivity and specificity of intraoperative 3D fluoroscopy in detecting dorsal screw protrusion are 83.3% and 98.2%, respectively. In comparison, the skyline view has a sensitivity of 62.5% and a specificity of 90.0%. SUMMARY
- The accuracy of the skyline view depends on using the appropriate fluoroscopic modality, wrist position, and the relationship with the imaging source.
- The skyline views offer only moderate evaluation of dorsal screw protrusion, whereas 3D fluoroscopy demonstrates nearly perfect agreement.
Given its high reliability and potential to reduce cumulative radiation exposure for surgeons seeking optimal skyline views, 3D fluoroscopy allows surgeons to remain away from the field during 3D scanning. This highlights 3D fluoroscopy as a invaluable modality
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