Name: orthopedic robot-assisted femoral neck system in the treatment of femoral neck fracture
Uploaded: 2023-03-03T13:45:00
Description: Watch this Scientific Journal Video about Orthopedic Robot-Assisted Femoral Neck System in the Treatment of Femoral Neck Fracture at JoVE.com

This work was supported by the Youth Cultivation Project of Xi&#39;an Health Commission (Program No. 2023qn17) and the Key Research and Development Program of Shaanxi Province (Program No. 2023-YBSF-099).

The present study was approved by the ethics committee of Honghui Hospital Xi&#39;an Jiaotong University. Informed consent was obtained from the patients.
1. Diagnosis of femoral neck fracture by X-ray fluoroscopy
<ol>
	<li>Identify patients who have a femoral neck fracture with tenderness or percussed pain around the hip joint, shortening of the lower extremity, limitation of the hip joint, etc.</li>
	<li>Use an antero-posterior (AP) view and a lateral view of an X-ray fluo...

<ol>
	<li>Thorngren, K. G., Hommel, A., Norrman, P. O., Thorngren, J., Wingstrand, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epidemiology+of+femoral+neck+fractures.">Epidemiology of femoral neck fractures.</a> Injury. 33, 1-7 (2002).</li><li>Lowe, J. A., Crist, B. D., Bhandari, M., Ferguson, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Optimal+treatment+of+femoral+neck+fractures+according+to+patient's+physiologic+age:+An+evidence-based+review.">Optimal treatment of femoral neck fractures according to patient's physiologic age: An evidence-based review.</a> The Orthopedic Clinics of North America. 41 (2), 157-166 (2010).</li><li>Stoffel, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biomechanical+evaluation+of+the+femoral+neck+system+in+unstable+Pauwels+III+femoral+neck+fractures:+A+comparison+with+the+dynamic+hip+screw+and+cannulated+screws.">Biomechanical evaluation of the femoral neck system in unstable Pauwels III femoral neck fractures: A comparison with the dynamic hip screw and cannulated screws.</a> Journal of Orthopaedic Trauma. 31 (3), 131-137 (2016).</li><li>Mei, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Finite+element+analysis+of+the+effect+of+cannulated+screw+placement+and+drilling+frequency+on+femoral+neck+fracture+fixation.">Finite element analysis of the effect of cannulated screw placement and drilling frequency on femoral neck fracture fixation.</a> Injury. 45 (12), 2045-2050 (2014).</li><li>Zheng, Y., Yang, J., Zhang, F., Lu, J., Qian, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+vs+freehand+cannulated+screw+placement+in+femoral+neck+fractures+surgery:+A+systematic+review+and+meta-analysis.">Robot-assisted vs freehand cannulated screw placement in femoral neck fractures surgery: A systematic review and meta-analysis.</a> Medicine. 100 (20), 25926 (2021).</li><li>Karthik, K., Colegate-Stone, T., Dasgupta, P., Tavakkolizadeh, A., Sinha, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+surgery+in+trauma+and+orthopaedics:+A+systematic+review.">Robotic surgery in trauma and orthopaedics: A systematic review.</a> The Bone and Joint Journal. 97-B (3), 292-299 (2015).</li><li>Garden, R. 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American Volume. 51 (4), 737-755 (1968).</li><li>Tang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Femoral+neck+system+versus+inverted+cannulated+cancellous+screw+for+the+treatment+of+femoral+neck+fractures+in+adults:+A+preliminary+comparative+study.">Femoral neck system versus inverted cannulated cancellous screw for the treatment of femoral neck fractures in adults: A preliminary comparative study.</a> Journal of Orthopaedic Surgery and Research. 16, 504 (2021).</li><li>Da Many, D. S., Parker, M. J., Chojnowski, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+after+intracapsular+hip+fractures+in+young+adults.+A+meta-analysis+of+18+published+studies+involving+564+fractures.">Complications after intracapsular hip fractures in young adults. A meta-analysis of 18 published studies involving 564 fractures.</a> Injury. 36 (1), 131-141 (2005).</li><li>Hamelinck, H. K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+of+computer-assisted+surgery+for+cannulated+hip+screws.">Safety of computer-assisted surgery for cannulated hip screws.</a> Clinical Orthopaedics and Related Research. 455, 241-245 (2007).</li><li>Wang, X., Lan, H., Li, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+femoral+neck+fractures+with+cannulated+screw+invasive+internal+fixation+assisted+by+orthopaedic+surgery+robot+positioning+system.">Treatment of femoral neck fractures with cannulated screw invasive internal fixation assisted by orthopaedic surgery robot positioning system.</a> Orthopaedic Surgery. 11 (5), 864-872 (2019).</li><li>Duan, S. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+percutaneous+cannulated+screw+fixation+of+femoral+neck+fractures:+Preliminary+clinical+results.">Robot-assisted percutaneous cannulated screw fixation of femoral neck fractures: Preliminary clinical results.</a> Orthopaedic Surgery. 11 (1), 34-41 (2019).</li><li>Zwingmann, J., Hauschild, O., Bode, G., S&#252;dkamp, N. S., Schmal, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Malposition+and+revision+rates+of+different+imaging+modalities+for+percutaneous+iliosacral+screw+fixation+following+pelvic+fractures:+A+systematic+review+and+meta-analysis.">Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: A systematic review and meta-analysis.</a> Archives of Orthopaedic &amp; Trauma Surgery. 133 (9), 1257-1265 (2013).</li><li>Zwingmann, J., Konrad, G., Kotter, E., S&#252;dkamp, N. P., Oberst, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Computer-navigated+iliosacral+screw+insertion+reduces+malposition+rate+and+radiation+exposure.">Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure.</a> Clinical Orthopaedics and Related Research. 467 (7), 1833-1838 (2009).</li><li>Stockton, D. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Failure+patterns+of+femoral+neck+fracture+fixation+in+young+patients.">Failure patterns of femoral neck fracture fixation in young patients.</a> Orthopedics. 42 (4), 376-380 (2019).</li><li>Wu, X. -. B., Wang, J. -. Q., Sun, X., Han, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidance+for+the+treatment+of+femoral+neck+fracture+with+precise+minimally+invasive+internal+fixation+based+on+the+orthopaedic+surgery+robot+positioning+system.">Guidance for the treatment of femoral neck fracture with precise minimally invasive internal fixation based on the orthopaedic surgery robot positioning system.</a> Orthopaedic Surgery. 11 (3), 335-340 (2019).</li></ol>

FNS is a method for fixing femoral neck fractures, which has the advantages of angular stability of the sliding hip screws and minimal invasiveness of the placement of the multiple cannulated screws. This method is less prone to screw cutting and irritation of the surrounding soft tissues. In Tang et al.&#39;s study9, compared with the CCS group, patients in the FNS group had lower rates of no or mild femoral neck shortness, shorter healing times, and higher Harris scores. Biomechanical studies ha...

Femoral neck fracture is one of the most common fractures in the clinic and accounts for about 3.6% of human fractures and 54.0% of hip fractures1. For young patients with femoral neck fractures, surgical treatment is performed to reduce the risk of nonunion and femoral head necrosis (FHN) by anatomical reduction and rigid internal fixation and to restore their function to the preoperative level as much as possible2. The most commonly used surgical treatment is fixation by three cannulated compression screws (CCS). With the increase in patient requirements, especially in young patients, the femoral neck system (FNS) is gradually being used, which combines the advantages of angular stability, minimal invasiveness, and better biomechanical stability than CCS for unstable femoral neck fractures3.
Traditionally, the screws were placed freehand by surgeons under fluoroscopic intraoperative guidance. The freehand method has many shortcomings, such as inability to plan the path intraoperatively, difficulty in controlling the direction of the guide wire during drilling, damage to the bone and blood supply due to repeated drilling, and penetration of the screw through the cortex due to improper positioning. These factors can directly or indirectly cause postoperative complications, such as fracture nonunion, FHN, and internal fixation failure, which influence the functional prognosis4. The freehand method has also been associated with increased radiation injury to patients and surgeons from frequent fluoroscopies5. Therefore, determining the optimal screw entry point and precise screw placement during pre-operative planning are key to the success of the operation. In recent years, robot-assisted minimally invasive internal fixation has been used with increasing frequency in orthopedic surgery6, and it is widely accepted by orthopedic surgeons because of its high precision and its ability to reduce the operation time and radiation injury. We applied the robot-assisted orthopedic surgery system to assist in FNS fixation for the treatment of femoral neck fractures, which resulted in a more accurate and efficient screw placement process, a higher success rate of the screw placement, and better functional recovery.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>C-arm X-ray</td>
			<td>Siemens&#160;</td>
			<td>CFDA Certified No:20163542280</td>
			<td>Type: ARCADIS Orbic 3D</td>
		</tr>
		<tr>
			<td>Femoral neck system</td>
			<td>DePuy, Synthes, Zuchwil, Switzerland</td>
			<td>CFDA Certified No: 20193130357</td>
			<td>Blot:length (75mm-130mm,5mm interval), 
			diameter (10mm); 
			Anti-rotation screw:length (75mm-130mm,5mm interval,match the lenth of the blot), 
			diameter (6.5mm); 
			Locking screw:length(25mm-60mm,5mm interval),diameter(5mm)</td>
		</tr>
		<tr>
			<td>Robot-assisted orthopedic surgery system</td>
			<td>Tianzhihang, Beijing,China</td>
			<td>CFDA Certified No:20163542280</td>
			<td>3rd generation</td>
		</tr>
		<tr>
			<td>Traction Bed</td>
			<td>Nanjing Mindray biomedical electronics Co.ltd.</td>
			<td>Jiangsu Food and Drug Administration Certified No:20162150342</td>
			<td>Type:HyBase 6100s</td>
		</tr>
	</tbody>
</table>

orthopedic robot-assisted femoral neck system in the treatment of femoral neck fracture

Cannulated screw fixation is the main therapy for femoral neck fractures, especially in young patients. The traditional surgical procedure uses C-arm fluoroscopy to place the screw freehand and requires several guide wire adjustments, which increases the operation time and radiation exposure. Repeated drilling can also cause damage to the blood supply and bone quality of the femoral neck, which can be followed by complications such as screw loosening, nonunion, and femoral head necrosis. In order to make fixation more precise and reduce the incidence of complications, our team applied robot-assisted orthopedic surgery for screw placement using the femoral neck system to modify the traditional procedure. This protocol introduces how to import a patient's X-ray information into the system, how to perform screw path planning in software, and how the robotic arm assists in screw placement. Using this method, the surgeons can place the screw successfully the first time, improve the accuracy of the procedure, and avoid radiation exposure. The whole protocol includes the diagnosis of femoral neck fracture; the collection of intraoperative X-ray images; screw path planning in the software; precise placement of the screw under the assistance of the robotic arm by the surgeon; and verification of the implant placement.

The robot-assisted orthopedic surgery system simulates the screw path virtually and assists in the precise placement of the screw, meaning this system has the advantages of being highly stable, having improved surgical precision and success rate, and having a lower risk of surgical trauma and radiation injury. Finally, the accuracy of the screw fixation results in a better clinical prognosis and a lower incidence of complications.
Patients diagnosed with a femoral neck fracture received surger...

Watch this Scientific Journal Video about Orthopedic Robot-Assisted Femoral Neck System in the Treatment of Femoral Neck Fracture at JoVE.com

Orthopedic Robot-Assisted Femoral Neck System in the Treatment of Femoral Neck Fracture

This article introduces a method of robot-assisted orthopedic surgery for screw placement during the treatment of femoral neck fracture using the femoral neck system, which allows for more accurate screw placement, improved surgical efficiency, and fewer complications.

Cannulated screw fixation is the main therapy for femoral neck fractures, especially in young patients. The traditional surgical procedure uses C-arm ...

Femoral neck fracture is common. Traditionally, we use a freehand method for screw placement. Now we apply the robot-assisted orthopedic surgery system in surgical manipulation, which has satisfactory results.The robot assess system could provide more accurate screw placement, a more efficient suture precise, reduced intraoperative radiation exposure, and achieve a better outcome. This system can be used in minimal invasive orthopedic surgery, particular in the procedure recurrent process screw placement, such as pelvic or acetabular fracture and the spine injury. Demonstrating the procedure, we have Yongchao Duan, an intraoperative imaging technologist, and Hai Huang, a surgeon from my department.To begin, identify the patient with a femoral neck fracture with tenderness or percussed pain around the hip joint. Fix the limb to the traction bed for continuous traction during the operation. Before starting the operation, connect the components of the robot-assisted orthopedic surgery system and unfold the robot arm.Log into the system and record the patient's medical records. After routine surgical disinfection, place a Schanz pin on the ipsilateral iliac wing, and fix the patient's tracer on the pin. Put sterile protective sleeves on the robotic arm and on the C-arm.Assemble the positioning ruler with the 10 identification points for the robot positioning system with the robotic arm. Position the C-arm x-ray machine centrally to the femoral neck, and put the robotic arm with the positioning ruler between the C-arm and the patient. Collect anteroposterior and lateral view X-ray images containing the 10 identification points of the positioning ruler.Import the anteroposterior and lateral view images containing 10 identification points, and the entire proximal femur into the workstation. Locate the screw channel in the center of the femoral neck with the neck shaft angle of 130 degrees, and parallel to the long axis of the femoral neck on the anteroposterior and lateral views. Locate the tip of the screw five millimeters under the cartilage of the femoral head.Replace the positioning ruler with the sleeve on the robotic arm. Run the robotic arm to the position of the entry point according to the planned path. Then make a three centimeter incision on the skin along the long axis of the femur with a knife.Blunt separate the subcutaneous tissue, and insert the sleeve to contact the bone cortex. Confirm the entry point and direction of the sleeve in accordance with the planned path. Drill the guide wire into the bone through the sleeve until it is five millimeters from the subchondral bone.Remove the robotic arm and check the position of the guide wire by x-ray. Ream the hole along the guidewire using a hollow drill bit, and insert the bolt and plate into the femoral head. Then place the anti-rotation screw and locking screw.After applying dynamic compression, verify the FNS placement with the bolt in the center of the femoral neck, both on the anterior, posterior and lateral views, and five millimeters from the subchondral bone and with the plate fitting the bone. Following the operation, suggest assisted passive hip flexion activities, and active exercise of the knee and ankle joints. The pre-operation x-ray images of the femoral neck fracture in anteroposterior and lateral view are shown here.The fracture was reduced by closed reduction to a proper position. The collected x-ray images using the patient tracer and the positioning ruler with the positioning ruler between the C-arm and the patient are demonstrated along with the fluoroscopy images containing the positioning ruler. Surgical path planning was performed on the software, and the screw channel was virtually displayed.The structure of the FNS process, the reaming process, the placement of the bolt and plate, the anti-rotation screw, and the locking screw are shown. X-ray images confirmed dynamic compression in anteroposterior and lateral view. This robot-assisted orthopedic surgery system simulates the screw plates virtually, assisting the screw placement precisely and reduce the risk of surgical procedure.

orthopedic-robot-assisted-femoral-neck-system-treatment-femoral-neck

Research

JoVE Journal

Medicine

Femoral Bone Marrow Aspiration in Live Mice

Serial sampling of the cellular composition of bone marrow (BM) is a routine procedure critical to clinical hematology. This protocol describes a detailed step-by-step technical procedure for an analogous procedure in live mice which allows for serial characterization of cells present in the BM. This procedure facilitates studies aimed to detect the presence of exogenously administered cells within the BM of mice as would be done in xenograft studies for instance. Moreover, this procedure allows for the retrieval and characterization of cells enriched in the BM such as hematopoietic stem and progenitor cells (HSPCs) without sacrifice of mice. Given that the cellular composition of peripheral blood is not necessarily reflective of proportions and types of stem and progenitor cells present in the marrow, procedures which provide access to this compartment without requiring termination of the mice are very helpful. The use of femoral bone marrow aspiration is illustrated here for cytological analysis of marrow cells, flow cytometric characterization of the hematopoietic stem/progenitor compartment, and culture of sorted HSPCs obtained by femoral BM aspiration compared with conventional marrow harvest.

This protocol describes a procedure for serial sampling of femoral bone marrow (BM) without requiring the sacrifice of mice. This procedure facilitates longitudinal studies of the BM composition of mice over time and provides serial access to cells within the BM for ex vivo and transplantation studies.

Serial sampling of the cellular composition of bone marrow (BM) is a routine procedure critical to clinical hematology. This protocol describes a detailed ...

A Simple Critical-sized Femoral Defect Model in Mice

While bone has a remarkable capacity for regeneration, serious bone trauma often results in damage that does not properly heal. In fact, one tenth of all limb bone fractures fail to heal completely due to the extent of the trauma, disease, or age of the patient. Our ability to improve bone regenerative strategies is critically dependent on the ability to mimic serious bone trauma in test animals, but the generation and stabilization of large bone lesions is technically challenging. In most cases, serious long bone trauma is mimicked experimentally by establishing a defect that will not naturally heal. This is achieved by complete removal of a bone segment that is larger than 1.5 times the diameter of the bone cross-section. The bone is then stabilized with a metal implant to maintain proper orientation of the fracture edges and allow for mobility. 
Due to their small size and the fragility of their long bones, establishment of such lesions in mice are beyond the capabilities of most research groups. As such, long bone defect models are confined to rats and larger animals. Nevertheless, mice afford significant research advantages in that they can be genetically modified and bred as immune-compromised strains that do not reject human cells and tissue.
Herein, we demonstrate a technique that facilitates the generation of a segmental defect in mouse femora using standard laboratory and veterinary equipment. With practice, fabrication of the fixation device and surgical implantation is feasible for the majority of trained veterinarians and animal research personnel. Using example data, we also provide methodologies for the quantitative analysis of bone healing for the model.

Animal models are frequently employed to mimic serious bone injury in biomedical research. Due to their small size, establishment of stabilized bone lesions in mice are beyond the capabilities of most research groups. Herein, we describe a simple method for establishing and analyzing experimental femoral defects in mice.

While bone has a remarkable capacity for regeneration, serious bone trauma often results in damage that does not properly heal. In fact, one tenth of all ...

Ultrasound Assessment of Flow-Mediated Dilation of the Brachial and Superficial Femoral Arteries in Rats

Arterial vasodilation to increases in wall shear rate is indicative of vascular endothelial function. In humans, the non-invasive measurement of endothelial function can be achieved by employing the flow-mediated dilation technique, typically performed in the brachial or superficial femoral artery. Briefly, a blood pressure cuff placed distal to an ultrasound probe is inflated to a suprasystolic pressure, which results in limb ischemia. After 5 min of occlusion the cuff is deflated, resulting in reactive hyperemia and increases in wall shear rate that signal vasodilatory molecules to be released from the endothelium eliciting vasodilation. Despite the thousands of studies performing flow-mediated dilation in humans, surprisingly, no studies have performed this technique non-invasively in living rats. Considering the recent shift in focus to translational research, the establishment of guidelines for non-invasive measurement of flow-mediated dilation in rats and other rodents would be extremely valuable. In the following article, a protocol is presented for the non-invasive measurement of flow-mediated dilation in brachial and superficial femoral arteries of rats, as those sites are most commonly measured in humans.

Non-invasive assessment of endothelial function in humans can be determined by the flow-mediated dilation technique. Although thousands of studies have used this technique, no study has performed this technique non-invasively in rats. The following article describes non-invasive measurement of flow-mediated dilation in the brachial and superficial femoral arteries of rats.

Arterial vasodilation to increases in wall shear rate is indicative of vascular endothelial function. In humans, the non-invasive measurement of ...

In Vivo Morphometric Analysis of Human Cranial Nerves Using Magnetic Resonance Imaging in Meni&#232;re's Disease Ears and Normal Hearing Ears

Analysis of neural structures in Meni&#232;re's Disease (MD) is of importance, since a loss of such structures has previously been proposed for this patient group but has yet to be confirmed. This protocol describes a method of in vivo evaluation of neural changes especially well suitable for cranial nerve analysis using magnetic resonance imaging (MRI). MD-patients and normal hearing persons were examined in a 3-T MR-scanner using a scan protocol including strongly T2-weighted 3D gradient-echo-sequence (3D-CISS). In the patient group, MD was additionally confirmed using MRI-based assessment of endolymphatic hydrops. Morphometric analysis was performed using a freeware DICOM viewer. Evaluation of cranial nerves included measurements of cross-sectional areas (CSAs) of the nerves at different levels as well as orthogonal diametric measurements.

To evaluate morphological changes of cranial nerves such as loss of neural structures or swelling of cranial nerves in Meni&#232;re&#39;s Disease (MD) or in healthy persons in vivo, a protocol of evaluation has been developed using magnetic resonance imaging (MRI). Additional MRI-based confirmation of MD was performed.

Analysis of neural structures in Meni&#232;re's Disease (MD) is of importance, since a loss of such structures has previously been proposed for this ...

Surgical Labyrinthectomy of the Rat to Study the Vestibular System

To study the vestibular system or the vestibular compensation process, a number of methods have been developed to cause vestibular damage, including surgical or chemical labyrinthectomy and vestibular neurectomy. Surgical labyrinthectomy is a relatively simple, reliable, and rapid method. Here, we describe the surgical technique for rat labyrinthectomy. A postauricular incision is made under general anesthesia to expose the external auditory canal and the tympanic membrane, after which the tympanic membrane and the ossicles are removed without the stapes. The stapes artery, which is located between the stapes and the oval window, is a vulnerable structure and must be preserved to obtain a clear surgical field. A hole to fenestrate the vestibule is made with a 2.1-mm drill bur superior to the stapes. Then, 100% ethanol is injected through this hole and aspirated several times. Meticulous dissection under a microscope and careful bleeding control are essential to obtain reliable results. Symptoms of vestibular loss, such as nystagmus, head tilting, and a rolling motion, are seen immediately after surgery. The rotarod or rotation chair test can be used to objectively and quantitatively evaluate the vestibular function.

This protocol describes the surgical labyrinthectomy of a rat, which is a useful method for studying the vestibular system.

To study the vestibular system or the vestibular compensation process, a number of methods have been developed to cause vestibular damage, including ...

The Generation of Closed Femoral Fractures in Mice: A Model to Study Bone Healing

Bone fractures impose a tremendous socio-economic burden on patients, in addition to significantly affecting their quality of life. Therapeutic strategies that promote efficient bone healing are non-existent and in high demand. Effective and reproducible animal models of fractures healing are needed to understand the complex biological processes associated with bone regeneration. Many animal models of fracture healing have been generated over the years; however, murine fracture models have recently emerged as powerful tools to study bone healing. A variety of open and closed models have been developed, but the closed femoral fracture model stands out as a simple method for generating rapid and reproducible results in a physiologically relevant manner. The goal of this surgical protocol is to generate unilateral closed femoral fractures in mice and facilitate a post-fracture stabilization of the femur by inserting an intramedullary steel rod. Although devices such as a nail or a screw offer greater axial and rotational stability, the use of an intramedullary rod provides a sufficient stabilization for consistent healing outcomes without producing new defects in the bone tissue or damaging nearby soft tissue. Radiographic imaging is used to monitor the progression of callus formation, bony union, and subsequent remodeling of the bony callus. Bone healing outcomes are typically associated with the strength of the healed bone and measured with torsional testing. Still, understanding the early cellular and molecular events associated with fracture repair is critical in the study of bone tissue regeneration. The closed femoral fracture model in mice with intramedullary fixation serves as an attractive platform to study bone fracture healing and evaluate therapeutic strategies to accelerate healing.

The murine closed femoral fracture model is a powerful platform to study fracture healing and novel therapeutic strategies to accelerate bone regeneration. The goal of this surgical protocol is to generate unilateral closed femoral fractures in mice using an intramedullary steel rod to stabilize the femur.

Bone fractures impose a tremendous socio-economic burden on patients, in addition to significantly affecting their quality of life. Therapeutic strategies ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robot-Assisted Kidney Transplantation

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. 
After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Augmented Reality Navigation-Guided Core Decompression for Osteonecrosis of Femoral Head

Osteonecrosis of the femoral head (ONFH) is a common joint disease in young and middle-aged patients, which seriously burdens their lives and work. For early-stage ONFH, core decompression surgery is a classical and effective hip preservation therapy. In traditional procedures of core decompression with Kirschner wire, there are still many problems such as X-ray exposure, repeated puncture verification, and damage to normal bone tissue. The blindness of the puncture process and the inability to provide real-time visualization are crucial reasons for these problems.
To optimize this procedure, our team developed an intraoperative navigation system on the basis of augmented reality (AR) technology. This surgical system can intuitively display the anatomy of the surgical areas and render preoperative images and virtual needles to intraoperative video in real-time. With the guide of the navigation system, surgeons can accurately insert Kirschner wires into the targeted lesion area and minimize the collateral damage. We conducted 10 cases of core decompression surgery with this system. The efficiency of positioning and fluoroscopy is greatly improved compared to the traditional procedures, and the accuracy of puncture is also guaranteed.

Augmented reality technology was applied to core decompression for osteonecrosis of the femoral head to realize real-time visualization of this surgical procedure. This method can effectively improve the safety and precision of core decompression.

Osteonecrosis of the femoral head (ONFH) is a common joint disease in young and middle-aged patients, which seriously burdens their lives and work. For ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...