jbjs est storyboard submission template: completed...

JBJS EST Storyboard Submission Template (Rev. 08/05/19) | 1

JBJS EST Storyboard Submission Template: COMPLETED SAMPLE

You are strongly encouraged to complete this storyboard form and submit it on the JBJS EST submission site along with the Title and Abstract form prior to producing your video to minimize post-production editing. After your storyboard has been peer-reviewed and approved, use it as the overall guide for video production and narration. Once the storyboard has been approved, the total video duration is typically 10 to 15 minutes. An example of a completed storyboard is provided here for your reference. Please do not include video clips in this storyboard. Any images used for the storyboard should be still photographs or line drawings only. The video content of every EST article should contain:

• Video file 1: procedure title, author and affiliations, citation of the peer-reviewed paper(s) reporting the outcome of the procedure, introduction

• Video file 2: procedure overview, preoperative planning • Video file 3: positioning and surgical exposure • Video file 4+: specific steps (in general, each video file should contain 1-3 steps; add additional video files as necessary for

longer procedures) • Video file # (next number in series): risks and complications, results • Video file # (next number in series): important tips, conclusion, and a complete list of references.

http://sites.jbjs.org/est/est_kp_storyboard_sample.docx


Instructions for Slide/Scene Descriptions and Narration

Please follow these instructions for all of the following boxes:

• In the left box, provide a DESCRIPTION OF A TEXT SLIDE OR VIDEO SCENE (or an image representing the slide or scene). • In the opposing right box, insert the actual SCRIPT OF THE NARRATION that will accompany each text slide or video scene.

Each box describing a slide or scene should be accompanied by a box with the narration for that slide or scene. • Please do not copy and paste text from any published article(s) into this form. • Please do not include video clips in this storyboard. Any images used for the storyboard should be still photographs,

radiographs or line drawings only. • Recommended times for each video file have been provided, but you may change them as necessary. • Append additional rows to this table if you wish to include more than one text slide or video scene.

Video File 1 Video Script PROCEDURE TITLE (5 sec) [Production note: Institutional logos may be displayed in the lower left corner of this slide.] Insert here: Radiofrequency Ablation of Osteoid Osteoma using Intraoperative 3D imaging and Surgical Navigation

Narration optional.

AUTHORS AND AFFILIATIONS (5 sec) [Production note: Institutional logos may be displayed in the lower left corner of this slide.] Insert here: Edward Y. Cheng, MD; Sameer M. Naranje, MBBS, MRCS(Glasgow); E. Russell Ritenour, PhD

Narration optional.


CITATION(S) THAT REPORT THE OUTCOME OF THIS PROCEDURE (5 sec) [Production note: Do NOT display institutional logos in the remainder of the slides/video files.] Provide full citations of the best peer-reviewed article(s) (no more than 3) that report the outcome of the procedure being described (the procedure of both the outcomes paper and this EST paper must be substantially equivalent). (A full reference list should be inserted at the end of the video.) Radiation Dosimetry of Intraoperative Cone-Beam Compared with Conventional CT for Radiofrequency Ablation of Osteoid Osteoma. Edward Y. Cheng, MD; Sameer M. Naranje, MBBS, MRCS(Glasgow); E. Russell Ritenour, PhD J Bone Joint Surg Am, 2014 May 07;96(9):735-742. http://dx.doi.org/10.2106/JBJS.M.00874

Narration optional.

INTRODUCTION OF VIDEO BY AUTHOR SPEAKING ON CAMERA (30-60 sec) In this box, indicate if you will deliver the introduction in the operating room, office, examining room, or other location: Author will introduce topic in an operating room setting.

Explain to the viewer the purpose of making this video, the importance of the procedure, how the procedure has evolved to this point, etc.: There are three advances that facilitated the development of performing radiofrequency ablation in the operative setting. The first is that surgeons traditionally only had two-dimensional fluoroscopic imaging for surgical guidance. Now with the development of intraoperative CT scans such as the O-arm unit here, repeated CT scans can be performed on the fly in the operating room as needed. Secondly, real-time surgical navigation is possible using infrared optical tracking arrays. These are typically attached to the target, as well as to surgical hand pieces that allow the surgeon to manipulate the hand piece relative to the anatomic target. The third is the development of cone beam CT technology which, results in a reduced radiation dose exposure to the patient as compared to conventional 64-slice CT scanners. In this video I hope to show you how to perform


this procedure and the particular steps that are necessary to perform it safely and efficiently.

GENERAL INTRODUCTION (1-3 min) In this box, describe the video scene to be shown. If a text slide is to be used, either the text alone, or a copy of the slide itself, is acceptable. In the text on the slide, include superscripted citations to references in the reference list that will appear at the end of the video. Text slide with XR’s of a sample case:

• Benign bone tumor1-3 o 3-4 % of all bone tumors o 11-12% of benign bone tumors

• Age: 5-20 years o Males> females

• Natural history: o Spontaneous resolution

• Rx: ASA and NSAID’s • Surgery:

o Excision (en bloc or curettage) o Radiofrequency ablation

Discuss background information and foundational knowledge, indications, contraindications, and importance and relevance of the procedure in the management of specific conditions. Also discuss the context of the procedure in relation to similar or alternative procedures. Briefly discuss the pros and cons of both this and alternative procedures, highlighting the rationale (or best clinical scenario) for choosing this procedure. “Osteoid osteomas are an unusual bone tumor and represent 3-4% of all bone tumors. However, among the benign bone tumors, they represent 11-12%. Patients typically are adolescents or young adults, and there is a slight predilection for males. Nearly all patients have non-activity-related pain. The natural history is for spontaneous resolution to occur, but this may take many years. Characteristically, aspirin or anti-inflammatory agents relieve the pain, but one must continue to take medications for many years. For this reason, most patients choose to have surgical treatment. In the past, this consisted of surgical excisions, either by en bloc resection or intralesional curettage. However, currently, radiofrequency ablation is considered the standard of care. This radiograph shows a typical osteoid osteoma in the lateral cortex of the proximal humerus. The coronal CT scan clearly demonstrates the lesion and the axial CT also shows the nidus within the anterolateral humeral cortex.”


Virtual image & CT image

“The top screen in blue color represents the surgeon’s view of the virtual image, demonstrating the position of surgical instruments being navigated in the surgical field relative to the target nidus. The bottom screen represents the CT scan image formed after 3-dimensional reconstructions using the O-arm software. In this particular case, the placement of two K-wires, best seen in the 2 CT images on the right, is confirmed within the nidus inside the humerus.”

“The indications for radiofrequency ablation are patients with painful osteoid osteomas, patients with symptoms unresponsive to analgesics, or patients in whom symptoms are responsive to medication but a prolonged course of treatment is considered undesirable. Finally, in rare cases, a secondary deformity may develop, such as a scoliosis.”


“The importance of radiofrequency ablation relative to other treatment options is that surgical incision involves curettage, en block resection or wide resection and bone grafting, and success rates of 90-100% are reported. However, there are complications as high as 20% in some series, with a 4.5% incidence of fractures. Radiofrequency ablation is advantageous in that it is minimally invasive, is successful in relieving pain in over 92% of patients, and has a lower risk of complications than surgical excision.”

“In surgical navigation, an optical infrared camera is used to track a target attached to an optical array. These arrays are attached to the target and any surgical instruments. The advantage of surgical navigation is the ability to see the target continuously, in real time, on a virtual image, without any radiation being emitted. Three common platforms for surgical navigation are the Medtronic StealthStation®, Brainlab, and Stryker’s navigation suite.”

“The O-arm uses cone beam CT technology. This emits only half the radiation dose of a conventional CT. Image contrast is excellent and bone visualization is superb. However, soft tissues are poorly seen. A conventional 64-slice CT scanner emits a higher radiation dose yet provides diagnostic-quality images of both bone and soft tissue.”


“A conventional 64-slice CT scanner emits a higher radiation dose yet provides diagnostic-quality images of both bone and soft tissue.”

“This is the typical image seen from an O-arm CT scanner that has been reformatted in three dimensions. Coronal, axial and sagittal views are available to interpret. In this case, an osteoid osteoma is targeted, as the intersecting green lines show, in the anteromedial humeral cortex.”

Video File 2 Video Script PROCEDURE OVERVIEW (1-2 min) In this box, insert an itemized list of the key steps of the procedure (i.e., Step 1, Step 2, Step 3, etc.). Procedure overview

1. Preoperative planning 2. Patient positioning and setup 3. Tracking optical array placement 4. O-Arm® setup and CT spin 5. CT data interpretation & approach planning 6. Surgical navigation setup

Provide accompanying narration here: “The specific steps to performing this procedure consist of preoperative planning, positioning the patient, applying a tracking optical array to both surgical instruments and to the target bone, O-arm setup and CT spins, interpreting the CT data and planning the surgical approach, setting up surgical navigation, inserting the K-wire into the nidus, exchange of the K-wire for a radiofrequency probe, and a confirmatory CT scan obtained before proceeding with the radiofrequency heating and burn.”


7. K-wire insertion and Nidus localization 8. Exchanging K-wire for a radiofrequency probe 9. RFA probe placement confirmation 10. Radiofrequency probe activation & closure

STEP 1: PREOPERATIVE PLANNING In this box, describe the video scene to be shown. If a text slide is to be used, a copy of the slide is acceptable. Emphasize important points during planning that contribute to a successful outcome. Pre-op planning

• Review images to confirm high level of confidence in radiologic diagnosis

– CT, Tc-99 bone scan, MR may be necessary to rule in or rule out other entities

• Determine best approach route and angle to nidus • Avoid neurovascular structures • Determine best position of patient or extremity on

OR table • Assess nidus size (single or double probe setup)

Provide accompanying narration here: “For preoperative planning, it is important to review all images and confirm a high level of confidence in the radiologic diagnosis. This includes both plain radiographs as well as CT scans, bone scan or possibly an MRI. Determining the best route of approach and angle of insertion of the probe into the nidus center is important. Be sure to avoid neurovascular structures and determine the best position of the patient on the operating table, to facilitate the probe insertion. Also, assess the nidus size, as large lesions may require two or more probes.”

Video File 3 Video Script

STEP 2: POSITIONING AND SURGICAL EXPOSURE (1-2 min) In this box, describe (or provide a photograph or line diagram showing) the positioning of the patient, surgical team, and equipment. Emphasize the steps you take to facilitate the subsequent performance of the surgery.

Provide accompanying narration here: “It is important to position and setup properly. We use a radiolucent operating table known as a Jackson table. Tucking the arms alongside the trunk, instead of laying them out on an armboard, allows room


for the O-arm to move laterally out of the way from the surgical field. Be sure there is a clean line of sight from the target to the StealthStation infrared camera, and position the O-arm screen and StealthStation screens opposite from the surgeon, as depicted in the photo, for easy viewing.”

Your video will then show a text slide stating “Surgical Exposure” (3 sec), after which you will orient the viewer to the anatomy during the exposure with a wide-angle view followed by the camera zooming in on a smaller field of view. In this box, describe (or provide a photograph or line diagram showing) a wide-angle view of the surgical field, illustrating laterality (i.e., right or left) and direction (e.g., proximal, distal, lateral, medial). On-screen text annotations to point out specific anatomic structures are very helpful for rapidly orienting the viewer. For arthroscopic or minimally invasive procedures, (a) indicate the anatomical portal and angle of view and (b) consider side-by-side simultaneous video display of both the camera view and the full, external surgical field view.

Provide accompanying narration here (e.g., “This is a view of the left glenohumeral joint as seen through an anterior deltopectoral exposure. Lateral is on the left of the screen and superior is at the top of the screen”).


In this box, describe (or provide a photograph or line diagram showing) a zoomed-in view focusing on the anatomical structure of interest.

Provide accompanying narration here: “This view of the patient’s right mid-tibia shows the surgeon making an incision on the anterior-medial crest of the tibia in preparation for placement of the optical tracking array.”

SPECIFIC STEPS OF THE PROCEDURE (each step: 1-2 min) These are the key scenes of the video. The procedure may be demonstrated on an actual patient, a Sawbones model, a cadaveric model, motion animation (animated drawing or image), etc. Line diagrams or drawings to illustrate anatomical features that may be difficult to visualize in a surgical setting are useful when displayed either side by side or as an inset image (picture in a picture). Describe (or provide images representing) each step, beginning with its title. Plan to use this title to clearly demarcate between the steps of your video by either running the title during the first three seconds of the video scene or using a title slide (3 sec).


Show unique instruments that are not widely available and mention where to obtain them. Text annotations may be used if narration is not possible or feasible. In the narration boxes, describe each step, while emphasizing specific pearls, tips, and tricks that may be of practical help or importance. Add or delete rows to this group as needed. For repetitive steps that need to be shown (e.g., inserting multiple screws), consider showing the repetitive portion of the video at 1.5× or 2× speed while attaching the narration, at normal cadence, separately. VIDEO FILE 4 Video Script STEP 3: Place the tracking optical array Video clip of tracking optical array placement

Provide accompanying narration here: “This video demonstrates the typical technique for placing half-pins in a long bone. It is the same technique as used to apply external fixators. The tracking array should ideally be placed in the same target bone as the lesion. This provides structural rigidity between the nidus and the tracking array. Select a site that has a sufficient distance from the nidus to avoid interfering with the probe placement. Rigid fixation of the tracking array is desirable to optimize navigation accuracy. Two types of tracking array fixations are possible. Two half-pins may be used as in this case, or in pelvic sites, a cruciate heel type of stem can be pounded into the posterior iliac crest instead.”

VIDEO FILE 5 Video Script STEP 4: Perform the CT with the O-Arm®

• Drape, rotate and close O-Arm® around the patient's target area

• Center the nidus within the field of view and perform a CT scan spin

Provide accompanying narration here: “After the array placement, the O-arm is rotated and closed around the patient and draped appropriately. The target nidus is centered within the field of view by using the O-arm’s AP and lateral scout fluoroscopic imaging. A CT spin is performed and the image data obtained is transmitted wirelessly to the StealthStation for analysis


• CT data is transmitted wirelessly to StealthStation for creation of virtual image of target to merge with surgical instruments

• Register a sterile mouse • Use mouse to manipulate images for analysis

and a virtual image is merged with the surgical instruments that are navigated. One uses a sterile mouse to manipulate the image for analysis, as shown in the following videos.”

Sterile remote mouse registration Video plays full screen

[Use original audio track on video]

VIDEO FILE 6 Video Script

STEP 5: Analyze the CT for nidus location and plan the approach

• Interpret and manipulate the data, using sterile technique with the help of wireless remote mouse pointing device on a separate, 3-D workstation with reconstructions in the axial, sagittal, and coronal planes

• Review all images and determine the approach and placement of the probe

Provide accompanying narration here: “The CT scan is formatted on a separate 3D workstation with use of the sterile mouse. Scroll through and interpret the images to analyze the best approach and angle of placement for the radiofrequency probe.”

Analyzing CT with O-arm workstation Video plays full screen

“This is a demonstration of using the sterile mouse to locate the target nidus. The field scrolls through images, while the upper left mouse button selects the image for analysis, as indicated by the yellow outline.”


STEP 6: Surgical navigation setup registration of K-wire guide

• Register surgical instruments to be tracked or navigated with the stealth workstation.

– Pointer

Provide accompanying narration here: “To track the surgical instruments, one must register them with the Stealth workstation. In this case, we use a pointer and a Kirschner wire drill guide. A K-wire, with a diameter a tiny bit larger than the probe, is used to drill the pilot hole for the probe. In this case, a cannulated dilator from a biopsy trephine set just happens to be the


– Kirschner wire drill guide (biopsy trephine set www.innomed.net)

• The workstation utilizes the 3-D data set collected, and matches this up with the surgical instruments and displays both the bone and instrument related each other on a screen separate from the O-Arm®, thus creating a virtual image on the stealth workstation that constantly updates in the real time

perfect size. The workstation will then utilize the CT data that had been collected and match this up with the surgical instruments and display both the bone and the instrument relative to each other on the screen as a virtual image that constantly updates in real time.” This is demonstrated in the following video.”

Registration of K-wire drill guide Video plays full screen demonstrating registration process

[Use original audio track on video]


STEP 7: Localize the nidus and insert K-wire

• Use the tracking pointer to navigate to the insertion site and determine the angle of approach to the target nidus. A K-wire is used to pre-drill a hole and then the wire is exchanged for the RFA probe*

• If nidus < 2 cm diameter, single 1 cm probe in the nidus’ center is sufficient. If nidus > 2 cm, 2 or more equally spaced probes may be necessary

Make a stab incision and dilate the soft tissues down to the bone using a clamp or other instrument

Provide accompanying narration here: “The nidus is localized with the assistance of a tracking pointer that is navigated to the insertion site. The appropriate angle of approach is determined, and a K-wire is then drilled into the center of the nidus and exchanged for a radiofrequency probe. The necrotic zone created is dependent upon the probe size. For a 1 cm probe, if the nidus is less than 2 cm in diameter, usually a single probe is satisfactory. However, if the nidus is large, for example greater than 2 cm, then two or more equally-spaced probes may be required. Make a stab incision and dilate the soft tissues down to the target bone and the location of the nidus using a clamp or other instrument.

Nidus localization

• Video plays full screen

“This video of the patient’s leg with the foot on the right, demonstrates how an instrument, in this case a pointer, is tracked continuously in real time and shown on the virtual CT image (as seen in the upper right inset screen). You can see the pointer is used to locate the nidus and determine where a stab incision is made. Then, the surgeon, while looking at the virtual CT image, uses this information to position the pointer directly over the target nidus. (31 sec) Pivoting the pointer in different angles relative to the target allows the surgeon to determine the best approach angle to get into the nidus. (48 sec) Linear motion of the pointer alongside the tibia is

http://www.innomed.net/


also shown both in the surgical field view and on the virtual image view. Notice how the tibia is stationary in the surgical live view while in the virtual CT image, the instrument stays stationary and the tibia moves instead.

K-wire insertion • Using the K-wire drill guide, navigate to the planned

insertion and approach path. Pre-load the K-wire (use the same diameter size as the RFA probe) in the guide to minimize any disruptive motion

• Measure the distance from the cortex to the far side of the nidus to determine the depth of wire insertion

• Under direct vision on the real time virtual image, insert the K-wire into the nidus while keeping the guide targeted properly along the proper angle of entry

• Perform a confirmatory CT Slide 23 – Nidus localization Video plays full screen

“After the planned insertion and approach pathway is determined, preload the K-wire in the wire guide and place it at the appropriate location for the target’s nidus. Measure the distance from the cortex to the far side of the nidus to determine how far to insert the K-wire. Under direct vision, while watching the real-time virtual image, drill and insert the K-wire into the center of the nidus, while keeping the guide targeted properly along the proper angle of entry. Afterwards, perform a CT scan to confirm proper placement. This video of the patient’s leg with the foot on the right, demonstrates how an instrument, in this case a pointer, is tracked continuously in real time and shown on the virtual CT image (as seen in the upper right inset screen). You can see the pointer is used to locate the nidus and determine where a stab incision is made. Then, the surgeon, while looking at the virtual CT image, uses this information to position the pointer directly over the target nidus. (31 sec) Pivoting the pointer in different angles relative to the target allows the surgeon to determine the best approach angle to get into the nidus. (48 sec) Linear motion of the pointer alongside the tibia is also shown both in the surgical field view and on the virtual image view. Notice how the tibia is stationary in the surgical live view while in the virtual CT image, the instrument stays stationary and the tibia moves instead.”

K-wire insertion Video plays full screen. Simultaneous side by side screen display of both the operative site and the stealth virtual image, in real time, will be shown. K-wire insertion

• Using the K-wire drill guide, navigate to the planned insertion and approach path. Pre-load the K-wire (use the same diameter size as the RFA probe) in the guide to minimize any disruptive motion

“The K-wire is now being inserted into the patient’s tibia. The foot is on the right and the tracking array on the left. The K-wire is placed in the guide, which is navigated. Using this navigated guide, the proper entry site and angle of insertion is determined while looking at the virtual CT image for guidance. The virtual CT image can also be used to measure the proper depth of insertion. Once the K-wire is placed into the stab incision and lined up accurately, the K-wire is drilled into the bone for the calculated depth and a confirmatory CT is performed to assess the placement accuracy. Any adjustments required are performed and another CT is performed as needed. After the planned


• Measure the distance from the cortex to the far side of the nidus to determine the depth of wire insertion

• Under direct vision on the real time virtual image, insert the K-wire into the nidus while keeping the guide targeted properly along the proper angle of entry

• Perform a confirmatory CT

insertion and approach pathway is determined, preload the K-wire in the wire guide and place it at the appropriate location for the target’s nidus. Measure the distance from the cortex to the far side of the nidus to determine how far to insert the K-wire. Under direct vision, while watching the real-time virtual image, drill and insert the K-wire into the center of the nidus, while keeping the guide targeted properly along the proper angle of entry. Afterwards, perform a CT scan to confirm proper placement.”

Slide 25 – K-wire insertion Video plays full screen

“The K-wire is now being inserted into the patient’s tibia. The foot is on the right and the tracking array on the left. The K-wire is placed in the guide, which is navigated. Using this navigated guide, the proper entry site and angle of insertion is determined while looking at the virtual CT image for guidance. The virtual CT image can also be used to measure the proper depth of insertion. Once the K-wire is placed into the stab incision and lined up accurately, the K-wire is drilled into the bone for the calculated depth and a confirmatory CT is performed to assess the placement accuracy. Any adjustments required are performed and another CT is performed as needed.”

Video File 9 Video Script Step 8: Exchange the K-wire for a probe Video plays full screen

Provide accompanying narration here: “This is a demonstration of the exchange of the K-wire for the radiofrequency probe. The probe is pre-positioned and placed parallel to a K-wire so that it may be immediately inserted in the same hole without losing the alignment and location of the cortical hole. This can be challenging when the nidus is in a deeply situated bone. The use of a soft tissue protector sleeve to maintain access to the cortical hole after K-wire removal is helpful. The K-wire is then removed and the probe is placed in the same hole that the K-wire was in. Be careful to place the probe at the same wire as the K-wire to ensure its proper position.”



Step 9: Confirm the RFA probe placement with a CT

Provide accompanying narration here: “This is a CT scan, of a different nidus in a tibia, confirming the proper placement of the probe within the center of the nidus. This is visualized on the axial, sagittal and coronal views. The K-wire should be in the exact location planned. If placement is suboptimal, repeat the targeting process as proper placement is critical to the success of the procedure.”

Angled trajectory into a rib nidus beside transverse process Provide accompanying narration here: “Surgical navigation is ideal for some lesions that are otherwise difficult to visualize. For example, this nidus located in a rib adjacent to a transverse process, would be difficult to localize without the benefit of surgical navigation and intraoperative CT scans in real time.”

Video File 11 Video Script Step 10: Activate the radiofrequency probe to burn the lesion & close

Provide accompanying narration here: “After the probe is in place, attach it to the radiofrequency generator. The generator is then turned on and the voltage is adjusted to maintain the temperature at 90 degrees Celsius for duration of 6 minutes. It may be necessary to do this twice if two probes are placed.”


CLOSURE (30 sec) If relevant, describe in this box the video scene to be shown. If a text slide is to be used, a copy of the slide is acceptable. Still image of extremity after wound closure

Provide accompanying narration here, mentioning caveats or technical considerations, such as soft-tissue handling, type of suture, method of skin closure, wound drain, immobilization needed, etc.: “Withdraw the probe after the RFA is completed. Remove the optical array from the bone as well. Then suture the skin for the percutaneous wounds as needed, and place a sterile dressing.”


Video File 13 Video Script RISKS AND COMPLICATIONS (30 sec) In this box, describe the video scene regarding risks and complications. If a text slide is to be used, a copy of the slide is acceptable.

• Fracture at the site of optical array placement • Neurovascular structure injury • Soft tissue or skin burn • Failed ablation (persistent pain) due to inaccurate

probe placement

Provide accompanying narration here: This procedure is performed percutaneously yet does incur some risks for the patient. Specifically, there is a risk of fracture due to bone weakening at the site of the optical array placement. This is increased when the array is mounted with half pins in cortical, as opposed to metaphyseal, bone. Additionally, the pathway for the probe insertion must be carefully planned to avoid injury to neurovascular structures. Using MR axial imaging to plan the route for probe placement is critical. When performing the ablation by raising the probe temperature, be sure to adequately shield the surrounding soft tissues from any uninsulated portion of the probe. Accurate probe placement is essential for a successful ablation. To ensure accurate placement, always confirm the probe position just prior to the ablation by performing a CT.

Video File 14 Video Script RESULTS (1 min) In this box, describe the video scene (or provide images) of a patient’s expected function after surgery. The best way to illustrate the outcome of a procedure is to show video of a patient demonstrating the procedure’s functional outcome (e.g., range of motion, function, gait, etc.) as a side by side display, before and after surgery. Also, in the narration, please describe, and/or provide a graph/table of, the expected results from the procedure as derived from the citations shown in Video File 1 . Mention the level of evidence that exists in the medical literature to support and verify the results of the procedure. Explain to the viewer what you would tell a patient who asks you about the goal and expected outcome of the procedure and the likelihood of attaining that goal or outcome.

Provide accompanying narration here: “In the last video of this series I am going to discuss the results of the study (http://jbjs.org/article.aspx?articleid=1864382) we conducted to compare three different techniques of radiofrequency ablation. In the first group of patients, the O-arm was used with surgical navigation. In the second group, only the O-arm CT scan was used, without surgical navigation. In the third group, a diagnostic-quality CT scan in a radiology suite was used. We looked at the radiation exposure, which is especially important in this group of patients, of a pediatric and adolescent age. The radiation exposure was nearly twice as great for those undergoing the CT scan technique, as opposed to the O-arm with or without navigation. This difference was statistically significant.”

http://jbjs.org/article.aspx?articleid=1864382


Results of Radiofrequency Ablation of Osteoid Osteoma

Survivorship curve

Provide accompanying narration here: “This survivorship curve demonstrates the outcome of treatment which is statistically the same regardless of which technique is used to target the lesion. Overall, 92% of patients were pain-free at a mean follow-up of 53 months. The vast majority of relapses will occur within the first year or two, as can be seen from this graph.”

Video File 15 Video Script IMPORTANT TIPS (1 min) In this box, demonstrate and discuss (in the narration) practical tips, technical tricks, pearls of wisdom, pitfalls, challenges, warnings, and any other teaching points you feel are helpful to ensure a successful outcome of the procedure.

• Try to approach the nidus in a direction perpendicular to the surface of the bone to avoid “skipping” or wandering of the K-wire when drilled into the bone. It may be necessary to position the patient or rotate an extremity a certain degree to attain this goal. Use cushions or a radiolucent “bean

Provide accompanying narration here: To facilitate the K-wire insertion into the nidus, an approach perpendicular to the bone surface is optimal. An approach in an oblique direction will have a tendency for the K-wire to wander off target as it is drilled into the bone. Re-position a patient as needed to optimize the approach direction. If a perpendicular approach is impossible due to other anatomical constraints, minimize the tendency for the probe to skive along the oblique bone surface by starting the K-wire insertion drill at high speed with minimal pressure against the bone. Exchanging the K-wire for the RFA probe can be difficult, especially in larger patients with a thick soft tissue envelope. Using a soft tissue


bag” appliance to support the patient and avoid any motion

• Use a soft tissue guide or sleeve to maintain the access to the probe insertion site when exchanging the K-wire for a probe

• Be familiar with the different probe sizes and tips and the associated zone of necrosis

• For a large nidus, use multiple probes inserted in a manner to assure treatment of the entire nidus in all planes

• Be careful to avoid bumping the optical array as any change in original position will introduce error in the positioning of the patient on the virtual screen

• If there is any question of accuracy on the virtual screen, confirm accuracy by placing the tracked pointer on a known anatomical bony landmark and visualizing this on the virtual screen.

protector sleeve to maintain access to the bony hole for probe insertion is helpful. Depending upon the manufacturer for the RFA probe, different tip sizes and lengths will have different geometries for the necrotic zone created after ablation. Be familiar with the probe sizes and choose accordingly to cover the entire nidus volume. Additionally, if a single probe will not achieve this goal, do not hesitate to use multiple probe insertions. We have not noted any complications from overlapping necrotic zones. The accuracy of the anatomical part displayed on the virtual screen is entirely depending upon a rigid connection between the optical array and the bone. Avoid any change in position of the optical array and if uncertainty occurs, check accuracy by placing the tracked pointer on a known anatomical landmark and confirm the proper position which should be displayed on the virtual screen.

CONCLUSIONS (2 min) In this box, provide a brief summary of the procedure and postoperative management, including: • Rehabilitation, immobilization, braces, splints, etc. • Therapy protocols • Postoperative medications (e.g., anticoagulant or

antibiotic use) • Imaging studies (e.g., for monitoring recovery) • Possible complications to monitor.

Conclusions

• Intraoperative O-arm CT has ~ ½ the radiation exposure of the radiology suite based CT technique. This is especially important in the pediatric and adolescent age group.

Provide accompanying narration here: “Our study demonstrated that usage of an intraoperative O-arm CT scan can reduce the radiation exposure to the patient by approximately one-half. This is especially important in the pediatric and adolescent age group, in whom these tumors occur. The outcome of treatment is the same regardless of whether an intraoperative CT scan or conventional diagnostic-quality CT scan is used to target the nidus. Over 90% of the patients have successful relief of pain. Thank you for watching our instructional video. We hope that you’ve found it beneficial in helping your understanding, so that you may be able to perform this safely, effectively and efficiently.”


• Intraoperative O-arm CT and conventional CT targeting techniques have similar outcomes with >90% success in relieving pain.

References (will appear as text beneath video) `Insert a list of references that support any statements made on the text slides and the outcomes of the procedure here: 1. Jaffe HL. Osteoid-osteoma. Proc R Soc Med. 1953 Dec;46(12):1007-12. 2. Kransdorf MJ, Stull MA, Gilkey FW, Moser RP Jr. Osteoid osteoma. Radiographics. 1991 Jul;11(4):671-96. 3. Cantwell CP, Obyrne J, Eustace S. Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol. 2004 Apr;14(4):607-17. Epub 2003 Dec 09. 4. Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ. Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am. 1998 Jun;80(6):815-21. 5. Theumann N, Hauser P, Schmidt S, Schnyder P, Leyvraz PF, Mouhsine E. [Osteoid osteoma and radiofrequency]. Rev Med Suisse. 2005 Dec 21;1(46):2989-94. Swiss. 6. Cantwell CP, Scanlon T, Dudeney S, O’Byrne J, Eustace S. CT guided radiofrequency ablation of intra-articular osteoid osteoma of the hip. Ir J Med Sci. 2005 Jul-Sep;174(3):97-9. 7. Skorpil M, Söderlund V, Brosjö O. [Radiofrequency ablation an effective invasive treatment]. Lakartidningen. 2004 Nov 25;101(48):3899-901. Swedish. 8. Thanos L, Mylona S, Kalioras V, Pomoni M, Batakis N. Percutaneous CT-guided interventional procedures in musculoskeletal system (our experience). Eur J Radiol. 2004 Jun;50(3):273-7. 9. Gibbs CP, Lewis VO, Peabody T. Beyond bone grafting: techniques in the surgical management of benign bone tumors. Instr Course Lect. 2005;54:497-503. 10. Eggel Y, Theumann N, Lüthi F. Intra-articular osteoid osteoma of the knee: clinical and therapeutical particularities. Joint Bone Spine. 2007 Jul;74(4):379-81. Epub 2007 May 15. Please submit this storyboard along with the Title Page and Abstract form via the Editorial Manager submission site. Do not begin filming until the storyboard has been approved. After your storyboard has been approved, it is imperative that you read the JBJS Author Video Guidelines and produce your video according to those guidelines.

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