Clinical bottom line
Intraoperative fluorescence imaging, particularly using indocyanine green (ICG), is an emerging technique to assess bone perfusion in real time during orthopedic surgery. Early evidence suggests it can provide objective visualization of bone vascularity, potentially aiding surgical decision-making in fracture fixation, amputation, and reconstructive procedures. However, current data remain limited and primarily from experimental or small clinical series. The technique shows promise for improving outcomes by identifying poorly perfused bone at risk for delayed healing or infection, but further validation in larger, controlled clinical studies is needed before routine adoption.
What the evidence shows
Recent studies have explored the utility of fluorescence imaging to assess bone perfusion intraoperatively. Tang et al. (2025) used ICG fluorescence imaging in a simulated fracture model to demonstrate that osteotomy and periosteal disruption significantly reduce bone perfusion, detectable in real time. This suggests the technique can sensitively reflect changes in bone vascularity during surgery. Wang Han et al. (2025) reported on the efficacy of ICG-based near-infrared angiography in assessing wound perfusion in bone and soft-tissue surgery, highlighting its potential to guide intraoperative decisions about tissue viability.
Quantitative dynamic contrast-enhanced fluorescence imaging has been applied to open orthopedic surgery by Gitajn et al. (2020), showing that perfusion parameters can be measured and correlated with clinical outcomes. Bessems et al. (2026) reviewed emerging intraoperative diagnostic modalities for fracture-related infection, noting fluorescence imaging as a promising tool for early detection of compromised bone perfusion, which may precede infection.
While the technique is well established in other surgical fields such as colorectal and pediatric surgery for assessing intestinal perfusion (Sevá-Pereira et al., 2025; Iinuma et al., 2016), its application in orthopedics is still evolving. Gebhard et al. (2025) emphasize the integration of advanced imaging modalities including fluorescence imaging with AI and 3D navigation to enhance orthopedic trauma surgery precision.
Caveats and uncertainty
Despite encouraging preliminary data, several limitations temper enthusiasm for routine clinical use. Most orthopedic studies are small, experimental, or observational, lacking large randomized controlled trials to confirm clinical benefit. The optimal timing, dosing, and interpretation criteria for ICG fluorescence in bone remain undefined. Bone perfusion is complex and influenced by multiple factors including patient comorbidities, surgical technique, and local anatomy, which may confound imaging results.
There is also a lack of standardized protocols for fluorescence imaging in orthopedics, and the technology requires specialized equipment and training. The cost-effectiveness and impact on long-term outcomes such as fracture healing rates, infection prevention, and implant survival are not yet established. Furthermore, fluorescence imaging assesses perfusion at a macrovascular level and may not fully capture microcirculatory or cellular-level ischemia relevant to bone viability.
How this may change practice
If validated in larger clinical studies, intraoperative fluorescence imaging could become a valuable adjunct in orthopedic surgery to objectively assess bone perfusion. This may help surgeons identify areas of compromised vascularity intraoperatively, allowing modification of fixation strategies, debridement extent, or soft tissue management to optimize healing potential and reduce complications such as nonunion or infection.
Fluorescence imaging could be particularly useful in complex trauma, revision surgery, and amputation procedures where bone viability is uncertain. Integration with other advanced intraoperative technologies like 3D navigation and AI may further enhance surgical precision. However, widespread adoption will require development of standardized imaging protocols, training, and demonstration of cost-effectiveness and improved patient outcomes.
For now, fluorescence imaging for bone perfusion assessment remains a promising but investigational tool that warrants cautious, hypothesis-generating use within research settings or specialized centers.