While traditional intraoperative fluoroscopy protection relies on thyroid shields and aprons, recent data suggest that the surgeon's eyes and hands receive more exposure than previously appreciated. ...Using a distal radial fracture surgery model, we examined (1) radiation exposure to the eyes, thyroid, chest, groin, and hands of a surgeon mannequin; (2) the degree to which shielding equipment can decrease exposure; and (3) how exposure varies with fluoroscopy unit size.
An anthropomorphic model was fit with radiation-attenuating glasses, a thyroid shield, an apron, and gloves. "Exposed" thermoluminescent dosimeters overlaid the protective equipment at the eyes, thyroid, chest, groin, and index finger while "shielded" dosimeters were placed beneath the protective equipment. Fluoroscopy position and settings were standardized. The mini-c-arm milliampere-seconds were fixed based on the selection of the kilovolt peak (kVp). Three mini and three standard c-arms scanned a model of the patient's wrist continuously for fifteen minutes each. Ten dosimeter exposures were recorded for each c-arm.
Hand exposure averaged 31 μSv/min (range, 22 to 48 μSv/min), which was 13.0 times higher than the other recorded exposures. Eye exposure averaged 4 μSv/min, 2.2 times higher than the mean thyroid, chest, and groin exposure. Gloves reduced hand exposure by 69.4%. Glasses decreased eye exposure by 65.6%. There was no significant difference in exposure between mini and standard fluoroscopy.
Surgeons' hands receive the most radiation exposure during distal radial plate fixation under fluoroscopy. There was a small but insignificant difference in mean exposure between standard fluoroscopy and mini-fluoroscopy, but some standard units resulted in lower exposure than some mini-units. On the basis of these findings, we recommend routine protective equipment to mitigate exposure to surgeons' hands and eyes, in addition to the thyroid, chest, and groin, during fluoroscopy procedures.
Abstract Pelvic ring fractures often result in severely injured patients with multiple organ injuries. The most common associated injuries are intraabdominal or urogenital, and urogenital injuries ...are the most common associated injuries in those with severe pelvic fractures. Prompt and effective diagnosis and management of these injuries is essential to successful outcomes, but this is potentially complicated by poor communication and coordination among the many specialists involved. To address this, we present a multi-disciplinary review of pelvic fracture-associated bladder and urethral injuries that is specifically geared towards orthopaedic, urology, and trauma surgeons caring for these patients.
The mechanical properties of bone tissue are determined by composition as well as structural, microstructural and nanostructural organization. The aim of this study was to quantify the elastic ...properties of bone at the lamellar level and compare these properties among osteonal, interstitial and trabecular microstructures from the diaphysis and the neck of the human femur. A nanoindentation technique with a custom irrigation system was used for simultaneously measuring force and displacement of a diamond tip pressed 500
nm into the moist bone tissue. An isotropic elastic modulus was calculated from the unloading curve with an assumed Poisson ratio of 0.3, while hardness was defined as the maximal force divided by the corresponding contact area. The elastic moduli ranged from 6.9±4.3
GPa in trabecular tissue from the femoral neck of a 74
yr old female up to 25.0±4.3
GPa in interstitial tissue from the diaphyseal cortex of a 69
yr old female. The mean elastic modulus was found to be significantly influenced by the type of lamella (
p<10
−6) and by donor (
p<10
−6). The interaction between the type of lamella and the donor was also highly significant (
p<10
−6). Hardness followed a similar distribution as elastic modulus among types of lamellae and donor, but with lower statistical contrast. It is concluded that the nanostructure of bone tissue must differ substantially among lamellar types, anatomical sites and individuals and suggests that tissue heterogeneity is of potential importance in bone fragility and adaptation.
We hypothesize that thumb basilar joint osteoarthritis (TBJA) radiographic stage does not correlate with patient-reported measures of symptom severity.
Patients with unilateral TBJA who completed the ...11-item QuickDASH (Disabilities of the Arm, Shoulder, and Hand), Short-Form 12 Health Survey (SF-12) Mental Component and SF-12 Physical Component surveys were prospectively enrolled in the study. The Eaton-Littler radiographic stage was assigned for each patient. The correlation between the radiographic score and disease stage was calculated.
Sixty-two patients (15 men, 47 women; average age, 62.3 years) formed the basis of this study. The average QuickDASH score (and standard deviation) for patients with stage 1 TBJA was 31.5 (11.4); for those with stage 2, it was 37.9 (17.4); with stage 3, it was 30.1 (13.0), and with stage 4, it was 39.4 (12.5). Eaton-Littler stage did not correlate significantly with QuickDASH scores (rho = -0.014, P = 0.91). Neither SF-12 Mental Component scores (MCS-12: rho = 0.019, P = 0.89) nor the SF-12 Physical Component scores (PCS-12: rho = 0.145, P = 0.26) correlated with TBJA stage.
Radiographic severity in TBJA does not correlate with validated patient-reported symptom scores. Metrics that link radiographic and subjective components of TBJA may improve surgical decision making and monitoring of treatment response.
Prognostic, level II.
Measuring the microscopic mechanical properties of bone tissue is important in support of understanding the etiology and pathogenesis of many bone diseases. Knowledge about these properties provides ...a context for estimating the local mechanical environment of bone related cells thait coordinate the adaptation to loads experienced at the whole organ level. The objective of this study was to determine the effects of experimental testing parameters on nanoindentation measures of lamellar-level bone mechanical properties. Specifically, we examined the effect of specimen preparation condition, indentation depth, repetitive loading, time delay, and displacement rate. The nanoindentation experiments produced measures of lamellar elastic moduli for human cortical bone (average value of 17.7 +/- 4.0 GPa for osteons and 19.3 +/- 4.7 GPa for interstitial bone tissue). In addition, the hardness measurements produced results consistent with data in the literature (average 0.52 +/- 0.15 GPa for osteons and 0.59 +/- 0.20 GPa for interstitial bone tissue). Consistent modulus values can be obtained from a 500-nm-deep indent. The results also indicated that the moduli and hardnesses of the dry specimens are significantly greater (22.6% and 56.9%, respectively) than those of the wet and wet and embedded specimens. The latter two groups were not different. The moduli obtained at a 5-nm/s loading rate were significantly lower than the values at the 10- and 20-nm/s loading rates while the 10- and 20-nm/s rates were not significantly different. The hardness measurements showed similar rate-dependent results. The preliminary results indicated that interstitial bone tissue has significantly higher modulus and hardness than osteonal bone tissue. In addition, a significant correlation between hardness and elastic modulus was observed.
Purpose To assess the incidence of ulnar nerve instability in patients undergoing in situ decompression and to identify preoperative risk factors to predict the need for transposition. Methods Using ...our surgical database, we retrospectively identified 363 patients who were candidates for in situ ulnar nerve decompression for the treatment of cubital tunnel syndrome over a 5-year period. During this time, the 3 participating surgeons considered ulnar nerve instability to be a contraindication for in situ ulnar nerve decompression. We collected demographic data including sex, age, weight, height, and body mass index. We recorded the number of patients who underwent ulnar nerve transposition owing to ulnar nerve instability and evaluated whether ulnar nerve instability was diagnosed before, during, or after surgery. Results Of the 363 patients who were considered for in situ ulnar nerve decompression, 76 patients (21%) underwent ulnar nerve transposition secondary to ulnar nerve instability. Twenty-nine patients (8%) were identified with instability before surgery, and 44 patients (12%) were identified with instability during surgery following in situ decompression. Three patients (1%) were not diagnosed with instability until after surgery and subsequently underwent secondary transposition. Patients who underwent transposition owing to instability were more likely to be male and to be younger. Conclusions A notable percentage of patients with a stable nerve before surgery will have ulnar nerve instability following decompression. Identification of factors correlating to instability and the potential need for transposition can aid surgeons and patients in preoperative planning. Type of study/level of evidence Prognostic II.
Background: Distal ulna fractures at the ulnar neck can be seen in association with distal radius fractures, and multiple techniques have been described to address the ulnar neck component of these ...injuries. We have found that treatment of ulnar neck fractures can be challenging in terms of anatomy and fracture fixation. We present a new percutaneous fixation technique for ulnar neck fractures commonly seen with distal radius fractures. Technique: Fixation of the ulnar neck fracture is performed after fixation of the distal radius fracture. Our technique uses anterograde intramedullary fixation to stabilize the fracture with a 1.6-mm (0.062 inch) Kirschner wire or a commercially available metacarpal fixation intramedullary nail. The fixation is introduced into the intramedullary space of the ulnar shaft 4 to 6 cm proximal to the fracture at a separate surgical site along the subcutaneous border of the ulna. The fixation is also supported with a sugar-tong splint for the first few weeks after surgery and requires removal of the ulnar implant approximately 10 weeks after implantation. Conclusion: Our technique utilizes a percutaneous approach with minimal fracture exposure. It provides a relatively simple and reproducible method to address ulnar neck fractures commonly seen in association with distal radial fractures.
Abstract Previous biomechanical studies have shown that the gift box technique for open Achilles tendon repair is twice as strong as a Krackow repair. The technique incorporates a paramedian skin ...incision with a midline paratenon incision, and a modification of the Krackow stitch is used to reinforce the repair. The wound is closed in layers such that the paratenon repair is offset from paramedian skin incision, further protecting the repair. The present study retrospectively reviews the clinical results for a series of patients who underwent the gift box technique for treatment of acute Achilles tendon ruptures from March 2002 to April 2007. The patients completed the Foot Function Index and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale. The tendon width and calf circumference were measured bilaterally and compared using paired t tests with a 5% α level. A total of 44 subjects, mean age 37.5 ± 8.6 years, underwent surgery approximately 10.8 ± 6.5 days after injury. The response rate was 35 (79.54%) patients for the questionnaire and 20 (45.45%) for the examination. The mean follow-up period was 35.7 ± 20.1 months. The complications included one stitch abscess, persistent pain, and keloid formation. One (2.86%) respondent reported significant weakness. Five (14.29%) respondents indicated persistent peri-incisional numbness. The range of motion was full or adequate. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score was 93.2 ± 6.8) and the mean Foot Function Index score was 7.0 ± 10.5. The calf girth and tendon width differences were statistically significantly between the limbs. The patients reported no repeat ruptures, sural nerve injuries, dehiscence, or infections. We present the outcomes data from patients who had undergone this alternative technique for Achilles tendon repair. The technique is reproducible, with good patient satisfaction and return to activity. The results compared well with the historical repeat rupture rates and incidence of nerve injury and dehiscence for open and percutaneous Achilles tendon repairs.
Metal allergy is an uncommon and poorly understood cause of failure of orthopedic implants. To the authors' knowledge, there have been no reports of the management of shoulder arthroplasty patients ...with metal allergy. The authors present their experience with the diagnosis and management of patients with metal allergy. Patients with metal allergy undergoing shoulder arthroplasty were identified through retrospective chart review from January 1, 2012, to January 31, 2015. Case characteristics collected included patient risk factors (age, sex, prior cutaneous reactions to metal), metal allergy factors (type of metal allergy, method of diagnosis), and surgery factors (implant type, primary/revision, type of shoulder arthroplasty). Outcomes measured included American Shoulder and Elbow Surgeons score, Penn Shoulder Score, and Single Assessment Numeric Evaluation score. Eleven patients were identified with metal allergy. Five were diagnosed prior to the index arthroplasty, and 6 were diagnosed after shoulder replacement. The diagnosis was made through skin patch testing, memory lymphocyte immunostimulation assay, or clinical history. Patients identified after implantation presented with progressive pain and stiffness, but none had cutaneous manifestations. Patients with metal allergy had better results undergoing primary shoulder arthroplasty than undergoing revision. Metal allergy is rare but may be a clinically significant cause of unsatisfactory shoulder arthroplasty. Given the superior results of primary shoulder arthroplasty compared with revision, screening for metal allergy by clinical history is recommended. Orthopedics. 2017; 40(5):e844-e848..
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