Skill dependence of radiation exposure for the orthopaedic surgeon during interlocking nailing of long-bone shaft fractures: a clinical study

The Application of a Surgery Supporting Computer System Does Not Seem to Influence the Surgeons' Radiation Exposure: A Retrospective Analysis

Since 2019, a surgery supporting system (SPM, surgical process manager; Johnson & Johnson, New Brunswick, New Jersey, Vereinigte Staaten) has been used in a Level I trauma center for common trauma surgery procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures, and spine fractures). The hypothesis of this study was that implementing standardized procedures (by using SPM) may reduce radiation exposure, especially for unexperienced surgeons.Workflows were developed for different surgical procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures, and spine fractures) and added into the SPM. Between October 2019 and June 2022, 90 surgeries using the SPM were included in the study. A control group was included with 107 surgeries using the same surgical technique. The values measured were the radiation exposure during the surgical procedure, the experience of the head surgeon, and whether or not the SPM was used. A statistical analysis was performed by using the chi square and Fischer exact tests, with significance set at a p value < 0.05.SPM was applicated in 51 cases for the distal radius (control group 54 patients), 20 cases for distal fibula fractures (control group 21 patients), 9 cases for the proximal femur (control group 19 patients), 5 cases for vertebral fractures (control group 7 patients), and 5 cases for the proximal humerus (control group 6 patients). No difference concerning the median radiation exposure was observed by plating distal radius fractures with 5.7 Gy/cm² in the SPM group and a median radiation exposure of 6.4 Gy/cm² in the control group (p = 0.96). The distal fibula fractures showed no significant difference in the intraoperative radiation (17.4 Gy/cm² vs. 6.4 Gy/cm², p value 0.53). Radiation exposure was lower when a consultant performed surgery without showing any significance, independent if SPM was used or not.In this study, no significant difference in the intraoperative radiation dose was observed when using a surgery supporting computer system. The experience of the surgeon showed no influence as well, regardless if SPM was used or not. Additional data should be collected questioning these findings.

Knowledge, Attitude, and Practices Regarding Radiation and its Hazards Among Orthopaedic Surgeons in India: A Questionnaire-Based Study

Introduction

Orthopaedic surgeons are among the most frequent users of radiation and are often exposed to X-Ray radiation regularly. There is an overall unsatisfactory level of knowledge, attitude, and practices regarding the same among surgeons. This study aimed to assess the practices among orthopaedic surgeons regarding radiation and its hazards in India.

Methodology

This questionnaire-based survey was conducted between March and September 2022. The questionnaire broadly assessed the knowledge, awareness, and practices among orthopaedic surgeons regularly exposed to X-ray radiation. The questionnaire consisted of objective and Likert scale questions which were distributed to the respondents electronically using publicly available contact information. A qualitative review of interpretations obtained from the responses and available evidence in the literature was then performed.

Results

The response rate for the survey was 36.4%. 65.9% reported using trunk protection all the time during procedures. 57.1% of respondents reported not using thyroid protection during procedures. 92.3% reported not using protective goggles and 100% did not use appropriate gloves. 76.9% were not issued dosimeters, and only 5.5% of those who had been issued one wore it during radiation procedures. 58.2% reported having a dedicated employee to operate the machine. 86.8% of respondents did not have formal training and 81.3% were not aware of institutes offering formal training.

Conclusion

There is very high compliance with the use of protection aprons among the respondents however, the use of other apparel like thyroid shields, protection goggles and gloves was poor. The awareness regarding radiation exposure was also poor as most respondents were not issued dosimeters, however, those issued with one were well aware of their exposure. It is imperative to prioritize both surgeons' and patients' safety where radiation exposure is concerned.

Are Indian orthopaedic surgeons aware of the health hazards of radiation exposure? A survey and review on awareness and ways to mitigate them

BACKGROUND

Standardized education on the short and long-term health hazards of radiation and thus the awareness regarding current radiation exposure limits is restricted in the field of orthopaedics. There is a lack of awareness regarding the risks related to radiation exposure amongst orthopaedic surgeons and therefore the recommended safety precautions to assess and mitigate these potential risks should be emphasized. Orthopaedic surgeons should adopt the ALARA (as low as reasonably achievable) principle. All precautions should be taken to keep all members of the operation room safe from radiation exposure and safeguard patients too.

METHODS

The survey questionnaire developed in consult with senior orthopaedic surgeons and radiation protection officer consisting of 27 questions was conducted among the orthopaedic surgeons and resident doctors.

RESULTS

15% responders were unaware about risks of radiation exposure in routine orthopaedic surgery and 82% unaware of the recommended yearly allowance per individual. 30% responders were unaware of correct positioning of the C-arm and 44% were unaware regarding the same distance to be maintained from the C-arm to reduce radiation exposure. 27% responders were unaware regarding pulsed fluoroscopy and its benefits. 45% responders were unsure regarding the thickness of the lead apron. 83% never use a thyroid gland shield and none of the responders use leaded eye glasses. Only 11% responders use lead badges for documentation of radiation exposure.

CONCLUSION

Orthopaedic surgeons should understand the basics and basis of radiation exposure limits, be familiar with this literature on the incidence of tumors, dermatitis, cancer risk and cataracts and understand the current intraoperative fluoroscopy safety recommendations. The damaging effects to human tissue caused by radiation exposure are documented since the first reports regarding use of radiographs, hence emphasis on radiation safety and protection should be universally incorporated into graduate medical education.

Radiation safety awareness and practices amongst orthopaedic surgeons in Scotland

As orthopaedic surgeons we use x-rays every day; not only when diagnosing pathology but often to assist in operative management of said pathology or ensure satisfactory outcomes for our patients in clinic. An awareness of the correct use of ionising radiation in the form of fluoroscopic imaging is therefore of great importance to reduce intraoperative exposure and has led to the development of the As Little As Reasonably Achievable (ALARA) principle. The primary aim of this study is to determine the knowledge and practises of radiation safety amongst orthopaedic surgeons in Scotland. Secondary aim is to assess the prevalence of back pain and relation to lead gowns. A google forms survey containing 20 questions about both an individual's radiation practises, and knowledge and departmental practises were distributed to all 4 deaneries in Scotland. In total 72 responses were received from 20 hospitals across all 4 Scottish deaneries. This included 28 Consultants, 23 Senior trainees and 21 Junior trainees. We found that the level of radiation training and knowledge varied considerably across seniority and the nation. Of those surveyed 100% reported always wear lead aprons/gowns however only 46.2% (n = 34) frequently or always wear thyroid protection when using X-rays. Only 55% (n = 40) of those surveyed had completed a radiation safety course with this being far less likely amongst junior trainees (29%, n = 6) than amongst Consultants (82%, n = 23) and senior trainees (48%, n = 11) (p < 0.0001). To our knowledge this is the most extensive survey into the radiation practises of Orthopaedic Surgeons in the literature and shows the need for increased education and awareness of radiation safety practises, particularly amongst junior trainees.

Endoscopy-assisted distal locking of an intramedullary nail: A new experimental technique to reduce radiation exposure during distal locking of the intramedullary nails

Objectives

In this study, we aimed to introduce a new technique in which distal locking step was easier and safer for orthopedic trauma surgeons involving in the treatment of long bone fractures using an intranail endoscopic visualization and illumination method.

Materials and methods

A total of 20 fresh bovine hind limbs derived from healthy adults and killed for sale were dissected to obtain tibial bones. Two equal groups including 10 samples in each were prepared. We applied a standard nailing process in both groups: the study group (n=10) was locked by the new technique, intranail endoscopic illumination guidance and intranail visualization assistance locking technique and the control group (n=10) was locked by the classical free-hand fluoroscopic guidance technique. We measured the surgical period time and the radiation exposure time required for the distal locking in both groups.

Results

The radiation exposure time was statistically significantly lower in the study group compared to the control group. Also, the time period required for distal locking in the study group were statistically significantly lower than the control group. With the use of the intranail endoscopic illumination guidance and visualization assistance technique, the median period time required for the distal locking procedure reduced from 477.5 to 223.5 sec (p<0.001). The median time for radiation exposure dramatically reduced from 13.5 to 2 sec (p<0.001). The median attempt number reduced from 6.5 to 2 times (p<0.001).

Conclusion

This experimental study indicates that the endoscopic illumination and intranail visualization assistance technique can reduce the radiation exposure time and the period time required for distal locking compared to the free-hand fluoroscopic guidance.

Augmented Reality (AR) in Orthopedics: Current Applications and Future Directions

PURPOSE OF REVIEW

Imaging technologies (X-ray, CT, MRI, and ultrasound) have revolutionized orthopedic surgery, allowing for the more efficient diagnosis, monitoring, and treatment of musculoskeletal aliments. The current review investigates recent literature surrounding the impact of augmented reality (AR) imaging technologies on orthopedic surgery. In particular, it investigates the impact that AR technologies may have on provider cognitive burden, operative times, occupational radiation exposure, and surgical precision and outcomes.

RECENT FINDINGS

Many AR technologies have been shown to lower provider cognitive burden and reduce operative time and radiation exposure while improving surgical precision in pre-clinical cadaveric and sawbones models. So far, only a few platforms focusing on pedicle screw placement have been approved by the FDA. These technologies have been implemented clinically with mixed results when compared to traditional free-hand approaches. It remains to be seen if current AR technologies can deliver upon their multitude of promises, and the ability to do so seems contingent upon continued technological progress. Additionally, the impact of these platforms will likely be highly conditional on clinical indication and provider type. It remains unclear if AR will be broadly accepted and utilized or if it will be reserved for niche indications where it adds significant value. One thing is clear, orthopedics' high utilization of pre- and intra-operative imaging, combined with the relative ease of tracking rigid structures like bone as compared to soft tissues, has made it the clear beachhead market for AR technologies in medicine.

Level of Supervision and Radiation Exposure of Senior Orthopedic Residents During Surgical Treatment of Proximal Femur Fracture

The sustained use of intraoperative fluoroscopy has led to increased use of minimally invasive surgical techniques, enhanced surgeon proficiency, improved anatomic corrections, reduced patient morbidity, earlier functional recovery, and decreased length of hospital stay. As a result, orthopedic attending surgeons and residents are exposed to more radiation, increasing the risk of cancer and radiation-induced cataracts compared with the general population and those who work in other surgical specialties. The magnitude of radiation exposure depends on the susceptibility of the tissues affected, medical specialty, the position of the C-arm, distance from the radiation beam, level of difficulty of the surgical procedure, surgeon experience, level of resident training, and level of supervision by the attending surgeon. However, little information is available on the effect of supervision level on radiation exposure for orthopedic senior residents. The goal of this study was to investigate whether level of supervision by the attending surgeon affects the radiation exposure of orthopedic senior residents during surgical treatment of proximal femur fracture with cephalomedullary nail fixation. This retrospective cohort study was performed from January 2019 to March 2019. No significant relationship between supervision level and radiation exposure of senior residents was observed. Supervision level does not significantly affect radiation exposure for senior residents; therefore, the implementation of standardized training in radiation safety may be a more essential measure to decrease radiation exposure. [Orthopedics. 2021;44(3):e402-e406.].

Does Surgical Experience Decrease Radiation Exposure in the Operating Room?

BACKGROUND

Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy.

METHODS

This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables.

RESULTS

A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases.

CONCLUSION

Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator's extremity from the field, and judicious use and placement of each additional pin.

LEVEL OF EVIDENCE

Level III.

Radiation exposure associated with percutaneous fluoroscopically guided lag screw fixation for sacroiliac luxation in dogs

OBJECTIVE

To determine radiation exposure to surgical personnel and to evaluate the accuracy of a modified percutaneous lag screw fixation technique for sacroiliac luxation (SIL) under fluoroscopic guidance in dogs.

STUDY DESIGN

Cadaveric experimental study.

SAMPLE POPULATION

Seventeen beagle cadavers with iatrogenic SIL.

METHODS

Seventeen beagles with iatrogenic SIL underwent reduction and stabilization with 3.5-mm screws. Hypodermic needles (14 gauge) and fluoroscopy were used to orient two Kirschner wires for temporary stabilization and to guide drilling of glide and pilot holes using cannulated drill bits. Duration of surgery and radiation exposure were recorded. Postoperative computed tomographic evaluation of screw position and angulation was performed.

RESULTS

Average time for fixation was 15.85 minutes (range, 6.37-33.5). Cumulative radiation doses of 0.4 mrem for the dominant arm of the assistant and 0 mrem for the primary surgeon were recorded. The mean dorsoventral and craniocaudal screw angles were 0.68° ± 3.4° (range - 5.4° to 9.5°) and 1.9° ± 3.2° (range - 4.3° to 9.1°), respectively. Sixteen of the 17 dogs had 100% sacral screw purchase, with the remaining case achieving 93.4% purchase.

CONCLUSION

Fluoroscopy-assisted percutaneous placement of 3.5-mm cortical screws in lag fashion performed with 14-gauge needles in conjunction with Kirschner wires and cannulated drill bits yielded repeatable accurate screw placement with low levels of ionizing radiation exposure to the surgical team.

CLINICAL SIGNIFICANCE

The described technique may be a viable method for minimally invasive osteosynthesis fixation of SIL with low levels of radiation exposure to the surgical team. These results provide evidence to support further evaluation of radiation exposure in clinical cases and can aid in study design and sample size determination.

Evaluation of the accuracy of the Sureshot® electromagnetic targeting system in distal locking of long-nailed humeral diaphyseal fractures

INTRODUCTION

Osteosynthesis of humeral diaphyseal fractures by long intramedullary nailing is a widespread practice. Distal interlocking is a delicate and uncertain step in the procedure, and the free-hand method is adopted by most surgeons. We evaluated the accuracy of a magnetic field-guided system for distal interlocking of long intramedullary nailed humeral diaphyseal fractures.

HYPOTHESIS

The field magnetic method to interlock distal screws procured satisfying success rates at first attempt in each hole.

STUDY DESIGN

Single center, retrospective, descriptive and continuous.

MATERIAL AND METHODS

We used the Sureshot® Distal Targeting System (DTS) and the Trigen® (Smith & Nephew) nail. All patients who presented to our center for osteosynthesis of a fracture of the humeral diaphysis by long intramedullary nailing between April 1, 2016 and June 30, 2018 were retrospectively included.

RESULTS

The analyses included 32 of the 34 patients who presented during this period (mean age, 64 years). There were 51 attempts to install distal interlocking screws. The screws were interlocked successfully in 40 cases (78.4%), and there were 11 failures (21.6%). There was an average of 29 fluoroscopic views and an average cumulative dose area product of 36.90 cGcm².

DISCUSSION

We found a lower success rate than that found in the literature for the accuracy of Sureshot® DTS in long humeral nailing. We found also a lower success rate than for tibial and femoral centromedullary nailing with this system. Our study showed a success rate of only 78.4% at the first attempt for distal interlocking of Trigen® humeral long nails.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Generic Implant Positioning Technology Based on Hole Projections in X-Ray Images

Implant placement plays a key role in trauma and orthopedics. In this paper, a generic technological concept for implant positioning assistance is outlined. The system utilizes conventional radiographic devices for imaging and tracking and embeds into surgical workflows without the need for complex navigation equipment. It is based on feature extraction from cylindrical hole-projections in X-ray images for determining spatial alignment of implant and anatomy. Basic performance of a prototype system was experimentally verified in terms of tracking accuracy and robustness under varying conditions. In a second step, the system was developed into a set of application modules, each serving a pressing clinical need: Plating of the proximal humerus, cephalic nail and dynamic hip-screw placement, general anatomic plating, distal nail interlocking with adjustment of femoral anteversion and corrective osteotomies. Module prototypes were tested according to their degree of maturity from feasibility assessment in wet-labs to clinical handling tests. Orientation tracking of reference objects yielded an accuracy and precision of 0.1±0.71 deg (mean±standard deviation) with a maximum error of 4.68 deg at unfavorable conditions. This base-performance translated, e.g., into a precision of ±1.2 mm (standard deviation) screw-tip to joint distance at proximal humerus plating, or into a precision of lag screw positioning in the femoral head of ±0.6 mm in craniocaudal and ±1.6 mm in anterioposterior direction. The concept revealed strong potential to improve surgical outcomes in a broad range of orthopedic applications due to its generic and simplistic nature. Comprehensive validation activities must follow for clinical introduction.

The Impact of Unguided Trauma Simulation Practice on Novice Performance: A Randomized Controlled Trial

INTRODUCTION

The purpose of this investigation was to determine the impact of simulator practice on task completion time, radiation use, success rate, and overall quality in a simulation of placing a distal locking screw.

METHODS

This was a prospective, randomized control trial with one-to-one randomization and parallel group design. Twenty-eight volunteer novice trainees (medical and premedical students) participated. Using the TraumaVision Virtual Reality Simulator (Swemac, Sweden), subjects performed locking screw placement using the "perfect circle" technique. All subjects underwent a pretest and posttest on the simulator. The simulator group completed three additional simulator training sessions. The primary outcome variables were simulator-collected task completion time, success rate, radiation exposure time, and overall score.

RESULTS

No notable difference existed between groups for pretest completion time, radiation use, success rate, or overall score. No notable difference in posttest radiation use or overall procedure score was found between groups. A significant difference existed in posttest total completion time (trained = 251.2 ± 103.4; control = 497.3 ± 223.1; P = 0.001) and success rate (64.3% versus 100%; P = 0.041) between groups. In addition, a significant difference existed in variance between groups for completion time (P = 0.029).

CONCLUSIONS

These findings suggest that independent simulator practice leads to improved speed and success rates; however, radiation use and overall score do not improve in the same manner. The design of simulator-based curriculum must be tailored to specific educational objectives and ultimately validated in the clinical setting.

Is Full-Length Intramedullary Nail Necessary for Atypical Subtrochanteric Femoral Fracture Associated with Bisphosphonate?

Background

American Society for Bone and Mineral Research recommend the use of intramedullary reconstruction of full length-nail for atypical subtrochanteric femoral fracture (ASFF). However, there is no study on the incidence of the ipsilateral femoral fracture after index operation of ASFF, and full-length nail has disadvantage as iatrogenic fracture and leg length discrepancy (LLD). The aim of this study was to investigate the incidence of ipsilateral secondary fracture after using partial-length nail, and to compare the outcomes on surgery of ASFF between partial length-nails and full length-nails.

Methods

Forty-five consecutive fractures with ASFFs which had undergone intramedullary fixation using cephalomedullary nail between 2011 and 2018 were enrolled. The 45 cases were grouped based on nail length into the partial-length nail group (n=26) and the full-length nail group (n=19). Ipsilateral secondary fracture, time to union, intra-operative iatrogenic fracture, metal failure, LLD, operative duration, and post-operative 24-hr blood loss were investigated.

Results

There was no ipsilateral secondary fracture after index operation. There were no statistically significant differences between the partial-length nail and full-length nail groups in the time to union, LLD, and post-operative 24-hr blood loss (P=0.427, 0.478, and 0.228, respectively). Operative duration showed statistically significant difference between 2 groups (P=0.034). Metal failure were occurred in 1 (3%) case of the partial-length nail group and 2 (10%) cases of the full-length nail group. Iatrogenic fractures during nail insertion occurred in 2 (7%) cases of the partial-length-nail group and 3 cases (15%) of the full-length nail group.

Conclusions

Although large scale studies are required, our study indicate that full-length nails are not usually required for the treatment of ASFF.

Radiation Exposure in Orthopaedics

» The damaging effects to human tissue caused by radiation exposure have been documented since the first reports regarding use of radiographs in the late nineteenth century. » Orthopaedic surgeons and residents often are undereducated about the risks associated with radiation exposure and the recommended safety precautions to help mitigate these potential risks. » Orthopaedic surgeons need to adopt the ALARA (as low as reasonably achievable) principle: whenever possible, all available precautions should be taken to keep all members of the operating room safe from radiation exposure while emphasizing the best appropriate care for patients. » An emphasis on radiation safety and protection should be universally incorporated into graduate medical education.

Suprapatellar tibial nailing: a learning curve analysis

PURPOSE

The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure.

METHODS

Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning.

RESULTS

Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period.

CONCLUSIONS

Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.

Does surgeon experience influence the amount of radiation exposure during orthopedic procedures? A systematic review

With an increasing use of intraoperative fluoroscopy in operating rooms worldwide, the topic of radiation exposure has become a major concern among hospital staff, doctors and patients alike. Since fluoroscopy has become an integral part in orthopedic intraoperative management, we sought to identify whether surgeon grade or experience plays a role in the amount of radiation used and consequently exposed. We performed a systematic review examining the association between surgeon experience and radiation exposure using primary outcome measures (radiation dose and total screening time/fluoroscopy time). To be included in the review, the study population had to compare varying surgeon experience levels and their effect on the primary outcomes. A total of eighteen studies were included in the review. The studies were a mix of prospective and retrospective studies with low to moderate quality as evaluated by the MINORs criteria. Studies were variable in defining surgeon experience levels and in the type of operations being performed. Majority of the studies showed that inexperienced surgeons/trainees had a higher total fluoroscopy time and a higher mean radiation exposure as compared to experienced surgeons. We conclude that higher surgeon experience significantly reduces usage of fluoroscopy and the consequent radiation exposure in orthopedic procedures. Introduction of strict radiation guidelines involving limited usage of fluoroscopy and supervision of trainees may be beneficial in controlling radiation exposure in the future.

Radiation Exposure to the Surgeon, Surgical Assistant, and Scrub Nurse During Closed Intramedullary Nailing of Long Bones-Does It Vary Depending on the Experience of the Surgeon?

OBJECTIVES

To assess radiation exposure (RE) to the surgical team and fluoroscopy time (FT) during closed nailing of long bone fractures performed under fluoroscopic guidance with regard to surgeon's experience.

DESIGN

Prospective observational study.

SETTING

Level-1 trauma center.

PARTICIPANTS

Surgical team, comprising a surgeon, a surgical assistant, and a scrub nurse, for closed nailing procedures performed in 202 consecutive closed tibial and femoral diaphyseal fractures.

INTERVENTION

Dosimeter provided to each member of surgical team. Surgeon experience level (trainee, senior registrar, and consultant).

MAIN OUTCOME MEASUREMENTS

RE (microsieverts) to the surgical team and FT (minutes) were recorded from the dosimeter and fluoroscopic unit, respectively, and correlated with surgeon's experience.

RESULTS

In tibial nailing, mean RE (in µSv) per procedure to surgeon, surgical assistant, and scrub nurse was 15.2, 9.2, and 2.0 for trainees, 14.5, 8.1, and 1.6 for senior registrars, and 13.6, 7.4, and 1.5 for consultants, respectively. In femoral nailing, mean RE per procedure to surgeon, surgical assistant, and scrub nurse was 181.6, 113.6, and 37.1 for trainees, 110.1, 66.7, and 20.4 for senior registrars, and 79.9, 30.9, and 12.5 for consultants, respectively. RE to the surgeon was highest followed by surgical assistant and scrub nurse irrespective of operating surgeon's experience in both tibial and femoral nailing (P < 0.001). In tibial nailing, there was a significant difference in FT only for the stage of guide wire passage (P = 0.041), whereas in femoral nailing, total FT (P < 0.001), nail entry verification (P = 0.02), guide wire passage (P = 0.013), nail introduction (P = 0.006), and distal locking (P < 0.001) showed a significant difference.

CONCLUSIONS

RE was maximum for operating surgeon and least for scrub nurse irrespective of operating surgeon's experience in both femoral and tibial nailing. FT and RE to the surgical team decreased with increasing experience of the surgeon in femoral nailing.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A New Preoperative Planning Technique Can Reduce Radiation Exposure During the Performance of Medial Opening-Wedge High Tibial Osteotomy

BACKGROUND

Medial opening-wedge high tibial osteotomy (HTO) is one of the most common and effective HTO techniques, in which the proximal tibia is cut medially, leaving an intact lateral hinge of bone that can be opened to a variable amount for the desired correction, but the technical complications of lateral cortex fracture and intra-articular fracture are well described. The lateral bone hinge for medial opening-wedge HTO is crucial. If the hinge is too small, the tibia can fracture and become unstable, requiring further fixation. If the hinge is too large, the osteotomy can propagate into the joint as an intra-articular fracture when opening the osteotomy.

PURPOSE

We propose a new technique that utilizes digital preoperative templating to improve the accuracy of the cut. Preoperative digital templating may allow the surgeon to reproducibly obtain a lateral bone hinge of 10 mm, while also reducing radiation exposure relative to the traditional fluoroscopically assisted technique.

METHODS

Ten cadaver extremities from five cadavers were matched into pairs and randomized into two groups: those with and without preoperative templating. The templating protocol measures the distance between two points on the medial and lateral cortices, and 20 mm is subtracted to determine the depth of the saw cut (10 mm for the hinge and another 10 mm because the proximal tibia is oval in shape). The control method was done by making the cut using fluoroscopy with tactile feedback. Postoperative computed tomography scans were obtained of all legs to measure the width of the lateral bone hinge. Intraoperative fluoroscopy used during both techniques and the numbers of fluoroscopy shots were recorded.

RESULTS

We found neither the treatment group with preoperative planning nor the control group with the conventional technique had bone hinge widths that were different from the ideal 10 mm. The average hinge widths for the treatment and control groups were 11.2 and 11.5 mm, respectively. However, the treatment group was exposed to significantly less intraoperative fluoroscopy during the osteotomy cut. The average total number of fluoroscopy shots was 2.2 in the treatment group versus 6.3 for the control group.

CONCLUSIONS

This new preoperative planning technique achieves similar accuracy of the lateral bone hinge when compared to current methods but exposes the patient, surgeon, and staff to significantly less intraoperative radiation.

Construct Validation of a Novel Hip Fracture Fixation Surgical Simulator

INTRODUCTION

A surgical simulation platform has been developed to simulate fluoroscopically guided surgical procedures by coupling computer modeling with a force-feedback device as a training tool for orthopaedic resident education in an effort to enhance motor skills and potentially minimize radiation exposure. The objective of this study was to determine whether the simulation platform can distinguish between novice and experienced practitioners of percutaneous pinning of hip fractures.

METHODS

Medical students, orthopaedic residents, orthopaedic trauma fellows, and attending surgeons completed in situ hip-pinning simulation that recorded performance measures related to surgical accuracy, time, and use of fluoroscopy. Linear regression models were used to compare the association between performance and practitioner experience.

RESULTS

Notable associations were shown between performance and practitioner experience in 10 of the 15 overall measures (P < 0.05) and 9 of 11 surgical accuracy parameters (P < 0.05).

CONCLUSION

This novel simulation platform can distinguish between novice and experienced practitioners and defines a performance curve for completion of simulated in situ hip pinning. This important first step lays the groundwork for subsequent validation studies, which will seek to demonstrate the efficacy of this simulator in improving clinical performance by trainees completing a sequence of skills-training modules.

Is there a need for standardized postoperative radiographs after operative treatment of wrist or ankle fractures?

PURPOSE

The purpose of this study was to evaluate the frequency of changes in treatment plan due to standardized postoperative radiographs. A secondary aim was to compare our results with a national benchmark.

METHODS

This is a single-center retrospective case series of 167 consecutive patients, operated with open reduction and internal fixation (ORIF) for distal radius or ankle fractures in 2014. Changes in the treatment protocol were defined as additional CT-imaging, reoperation or other changes as stated in the postoperative instructions. In addition, a national survey was conducted assessing differences between surgeons in different hospitals concerning revision rates.

RESULTS

In 7.2% (12/167) of the patients, a change in the treatment plan was recorded after the standardized postoperative radiographs. 10 patients (6%) were reoperated (three without additional imaging, seven after additional imaging with CT). The results from our survey showed a good assessment concerning the quality of intraoperative imaging (7.85 on a scale from 0 to 10). Concerning the revision rate, there was a trend to lower revision rate of 8.1% in the six observers.

CONCLUSIONS

Standard postoperative radiographs could improve quality of care. Intraoperative standardized radiographic documentation is needed and the perception and acceptance of quality may vary between hospitals.

Comparison of free-hand fluoroscopic guidance and electromagnetic navigation in distal locking of tibia intramedullary nails

BACKGROUND

It is challenges for surgeon to position the distal locking screw of a tibia intramedullary nail. The traditional free-hand (FH) technique is related to the proficiency of surgeons and has a long learning curve. Furthermore, the radiation dose and the accuracy of screw placement should be taken into account. The new technology, the electromagnetic navigation system (ET), which is a radiation-free way to locate the position of the drill bit. The purpose of our study is to evaluate the results of the ET for distal locking screw of a tibia intramedullary nail and to compare the effects with the FH technique.

METHODS

Eighty-nine cases of tibia diaphyseal fracture who needed to treat by intramedullary nails were analyzed retrospectively, and were divided into 2 groups. Patients in navigation group (n = 54) were treated with intramedullary nail using the ET for distal locking, while other 35 patients using FH technique. Intraoperative fluoroscopy exposure times, screw insertion times, and healing times were recorded. The parameter was used for comparison in 2 groups.

RESULTS

The mean time of distal locking in the ET technique was significant less than that in the FH group (5.89 ± 2.02 minutes vs 12.26 ± 4.40 minutes) and the exposure time was reduced in ET group significantly (2.13 ± 0.73 seconds vs 19.09 ± 10.41 seconds). The healing time was proved to be coincident in FH group and ET group (15.34 ± 2.98w vs 16.06 ± 3.74w). The one-time success rate of distal locking nail operation was 100% in the navigation group, which was significantly higher than that in FH group (P < .05).

CONCLUSION

Compared with the FH technique, the ET for distal locking of tibia intramedullary nail has the advantages of high efficiency and short locking time without radiation.

Radiation Exposure and Health Risks for Orthopaedic Surgeons

Orthopaedic surgeons are routinely exposed to intraoperative radiation and, therefore, follow the principle of "as low as reasonably achievable" with regard to occupational safety. However, standardized education on the long-term health effects of radiation and the basis for current radiation exposure limits is limited in the field of orthopaedics. Much of orthopaedic surgeons' understanding of radiation exposure limits is extrapolated from studies of survivors of the atomic bombings in Hiroshima and Nagasaki, Japan. Epidemiologic studies on cancer risk in surgeons and interventional proceduralists and dosimetry studies on true radiation exposure during trauma and spine surgery recently have been conducted. Orthopaedic surgeons should understand the basics and basis of radiation exposure limits, be familiar with the current literature on the incidence of solid tumors and cataracts in orthopaedic surgeons, and understand the evidence behind current intraoperative fluoroscopy safety recommendations.

WEIGHT-BEARING COMPUTED TOMOGRAPHY OF THE FOOT AND ANKLE: AN UPDATE AND FUTURE DIRECTIONS

Spatial understanding of osteoarticular deformities of the foot and ankle is vital to correct diagnosis and therapeutic decision making. Poor reproducibility in conventional standing radiography in three orthogonal views has driven the development of weight-bearing computed tomography (WBCT) technology over the last decade. We analyzed the available literature on WBCT imaging in patients with foot and ankle disorders by performing a literature review of relevant clinical studies in multiple databases including PubMed, MedLine, and Scopus from January 1999 to October 2017. WBCT imaging allows correct evaluation of foot and ankle anatomy with the patient in a standing position, providing images with high spatial resolution, short image acquisition time, low dose of radiation, and costs which are similar to other available imaging technologies. This diagnostic tool can be used for decision making in the treatment of deformities of the ankle, hindfoot, midfoot, and forefoot. Level of Evidence III; Systematic review of level III studies.

The Influence of Resident Level of Training on Fluoroscopy Time in Pediatric Supracondylar Humeral Fractures Treated with Closed Reduction and Percutaneous Pinning

Objective The purpose of this study was to evaluate the effect of resident level of training on fluoroscopy duration in pediatric supracondylar humeral fractures treated with closed reduction and percutaneous pinning (CRPP). Methods After classifying the surgeons according to their seniorities, the duration of fluoroscopy time of 80 patients with extension type III supracondylar fractures during reduction and pinning was recorded. Results The time duration of reduction procedures was similar in all groups with respect to the surgical experience; however, time durations of percutaneous pinning procedures were found statistically different between groups (p=0.042). Conclusion Surgical experience is very important in the management of supracondylar humeral fractures in children, especially in percutaneous pinning rather than closed reduction.

Developing an objective assessment of surgical performance from operating room video and surgical imagery

An unbiased, repeatable process for assessing operating room performance is an important step toward quantifying the relationship between surgical training and performance. Hip fracture surgeries offer a promising first target in orthopedic trauma because they are common and they offer quantitative performance metrics that can be assessed from video recordings and intraoperative fluoroscopic images. Hip fracture repair surgeries were recorded using a head-mounted point-of-view camera. Intraoperative fluoroscopic images were also saved. The following performance metrics were analyzed: duration of wire navigation, number of fluoroscopic images collected, degree of intervention by the surgeon's supervisor, and the tip-apex distance (TAD). Two orthopedic traumatologists graded surgical performance in each video independently using an Objective Structured Assessment of Technical Skill (OSATS). Wire navigation duration correlated with weeks into residency and prior cases logged. TAD correlated with cases logged. There was no significant correlation between the OSATS total score and experience metrics. Total OSATS score correlated with duration and number of fluoroscopic images. Our results indicate that two metrics of hip fracture wire navigation performance, duration and TAD, significantly differentiate surgical experience. The methods presented have the potential to provide truly objective assessment of resident technical performance in the OR.

DETERMINATION OF LOCAL LEVELS OF RADIATION EXPOSURE IN ORTHOPEDIC INTERVENTIONS USING STRUCTURED DOSE REPORT DATA DRAWN FROM THE HOSPITAL PICTURE ARCHIVING AND COMMUNICATION SYSTEM

The aim of this study was to determine the dosimetric parameters of radiation to which orthopedic in-patients are exposed, using data drawn from the hospital's picture archiving and communication system. Data for 310 patients, relating to seven different anatomical districts, were examined. Femoral operations were divided into three types. The 75th percentile dose at the interventional reference point (IRP) exceeded 2 mGy only for femoral interventions (4.6-6.2 mGy) with 75th percentile kerma-area product (KAP) values ranging from 84.8 to 109.1 μGy m2. The 75th percentile fluoroscopy time was longer than 1 min only for the humeral operations and the three types of femoral intervention. In general, the radiation exposure times and doses recorded in our institute were lower than those reported in the literature. The correlation between KAP and kerma at the IRP was very strong for all districts (R > 0.80). The correlation between KAP and fluoroscopy times was very strong for seven cases (R > 0.80), and strong for two (0.60 < R < 0.79).

Exposure of medical staff to radiation during osteosynthesis of proximal femoral fracture: descriptive analysis and comparison of different devices

BACKGROUND

The use of fluoroscopy is necessary during proximal femoral fracture (PFF) osteosynthesis. The frequency of these procedures justifies a description of radiation exposure and comparisons between different techniques and between the different surgical team members.

METHODS

This observational prospective and comparative study includes a series of 68 patients with PFF receiving osteosynthesis. Radiation exposure was assessed for all members of the operating team. The radiation dose measurements for the different members of the surgical team during PFF osteosynthesis were compared. The factors affecting the radiation dose were investigated.

RESULTS

The mean active dosimeter readings for each operation were 7.39 µSv for the primary surgeon, 3.93 µSv for the assistant surgeon, 1.92 µSv for the instrument nurse, 1.25 µSv for the circulating nurse, and 0.64 µSv for the anaesthesiologist, respectively. Doses decreased significantly between these different members of the medical team (all p < 0.001). The dose also varied with patient age and BMI, as well as with fluoroscopy time and operating time, but not with type of fracture or type of osteosynthesis.

CONCLUSION

Medical staff receives significantly different doses depending on their position in relation to the radiation source. Operating time and fluoroscopy time are the modifiable factors that affect the radiation dose. The radiation doses received by the different members of the medical teams involved in proximal femur osteosynthesis procedures all fall below the doses recommended by the International Commission on Radiation Units and Measurements.

The Great Unknown-A systematic literature review about risk associated with intraoperative imaging during orthopaedic surgeries

INTRODUCTION

Modern techniques in orthopaedic surgery using minimally invasive procedures, and increased use of fluoroscopic imaging present a potential increased risk to surgeons due to ionizing radiation exposure. This article is a systematic review of recent literature on radiation exposure of orthopaedic surgeons.

MATERIALS AND METHODS

Pubmed and Cochrane searches were performed on intraoperative radiation exposure covering English and German articles published between 1.1.2000 and 11.8.2014. Inclusion criteria were clinical studies and systematic literature reviews focusing on radiation exposure of orthopaedic surgeons during surgical procedures of the musculoskeletal system reporting either effective dose (whole body) or equivalent dose at the organ level. All included articles were reviewed with focus on the surgical specialty, the procedure type, the imaging system used, the radiation measurement method, the fluoroscopy time, the radiation exposure, the use of radiation protection, and any references to specific safety guidelines.

RESULTS

Thirty-four eligible publications were identified. However, the lack of well-designed studies focusing on radiation exposure of surgeons prevents pooling of data. Highest exposure and subsequent equivalent doses were reported from spinal surgery (up to 4.8mSv of equivalent dose to the hand) and intramedullary nailing (up to 0.142mSV of equivalent dose to the thyroid). Radiation exposure was reduced by 96.9% and 94.2% when wearing a thyroid collar and a lead apron.

CONCLUSIONS

With the increasing use of intraoperative imaging, there is a growing need for radiation awareness by the operating surgeon. Strict adherence to radiation protection should be enforced to protect in-training surgeons. Strategies to reduce exposure include C-arm position, distance, protective wear, and new imaging technologies. Radiation exposure is harmful and action should be taken to minimize exposure.

Comparison of free-hand fluoroscopic guidance and electromagnetic navigation in distal locking of femoral intramedullary nails

BACKGROUND

Although the method has been used widely, one of the greatest challenges for intramedullary nailing is to position the distal locking screw. A new technology, the electromagnetic navigation system, is a radiation-free way to locate the position of the drill bit and provide 3-dimensional real-time feedback of location and orientation of the drill bit relative to the locking holes. The purpose of our study was to evaluate the reliability and efficiency of the free-hand technique compared to the new electromagnetic navigation system.

METHODS

Fifty-four patients with femoral fracture who needed treatment with intramedullary nails were divided into 2 groups. One group including 26 patients underwent distal locking using the standard free-hand method, whereas the electromagnetic navigation system was used with the other 29 patients. Intraoperative fluoroscopy exposure times, screw insertion times, and healing times were recorded; these parameters were used for comparison between the 2 groups.

RESULTS

There were 17 males and 9 females who had femoral intramedullary nails using the free-hand technique, whereas 21 males and 8 females received intramedullary nails using the electromagnetic navigation system. The mean time of distal locking was 19.5 ± 6.0 minutes in the free-hand (FH) group, whereas the time was 6.1 ± 1.4 minutes in the electromagnetic (ET) group. The exposure time for the FH group was 26.8 ± 13.3 seconds and 2.2 ± 1.1 seconds for the ET group. Healing time proved to be comparable in the FH and ET groups (16.4 ± 3.7 weeks vs 15.1 ± 2.8 weeks).

CONCLUSION

Under the premise of achieving the same effect, the electromagnetic navigation system has the advantage of less distal locking time and less radiation dose.

Radiation exposure during intramedullary nailing

Surgeons should aim to keep radiation exposure "As Low As Reasonably Achievable (ALARA)" during intramedullary nailing and other minimally invasive surgical procedures. This requires understanding the principles of ionizing radiation and methods for minimizing exposure risk. The main source of radiation exposure to surgical personnel during fluoroscopy is from scattered radiation. Since radiation scatter is mainly directed towards the fluoroscopy source, the best configuration during surgery to reduce radiation dose to the surgeon is to position the fluoroscopic source below the operating room table and the image collector above the table. During cross table imaging, the surgeon should stand on the side with the image collector to minimize their exposure to radiation scatter. To reduce scattered radiation the patient must be placed as close to the image collector and as far away from the x-ray tube as possible. Standing farther away from the patient can exponentially reduce radiation exposure. The hands usually have the greatest dose exposure to radiation during surgical procedures, but they are far less radiosensitive than the eyes or thyroid. To minimize exposure to the hands, a surgeon should use the hands-off technique taking fluoroscopic images only when his or her hands are farthest from the radiographic field. Lead gowns, lead thyroid shields, and lead glasses, further reduces an individual's exposure to radiation.

The outcomes of pediatric femoral shaft fractures treated surgically by different types of orthopedists

BACKGROUND

The objective of this study was to compare the outcomes of pediatric femoral shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists.

METHODS

From May 2006 to June 2014, 88 children with femoral shaft fractures were randomized to operative stabilization either by pediatric orthopedists (Group A, 44 cases) or by non-pediatric orthopedists (Group B, 44 cases). Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, associated injuries and interval from injury to surgery) were comparable between the two groups before surgery. Peri-operative data, clinical and functional outcomes between the two groups were recorded.

RESULTS

The mean follow-up period was 20.9±4.5months for Group A and 20.0±3.6months for Group B (P=0.356). There was no significant difference in the time to union, length of hospitalization, full weight-bearing time and TEN scores between the two groups (P=0.785, P=0.835, P=0.803, P=0.940, respectively). However, the mean operating time and radiation time was longer in Group B than in Group A (P=0.001 and P=0.047, respectively). Also, there was a trend for patients of Group B to have a higher rate of open reduction (P=0.047). When comparing the total complications, no significant difference existed between the groups (P=0.978).

CONCLUSIONS

This study indicated that both pediatric and non-pediatric orthopedists provided satisfactory clinical and functional results in treating these common injuries.

Fluoroscopic freehand and electromagnetic-guided targeting system for distal locking screws of humeral intramedullary nail

PURPOSE

The current techniques used to lock distal screws for the nailing of long bone fractures expose the surgeons, radiologists and patients to a hearty dose of ionizing radiation. The Sureshot™ Distal Targeting System is a new technique that, with the same results, allows for shorter surgery times and, consequently, less exposure to radiation.

MATERIALS AND METHODS

The study was performed on 59 patients (34 males and 25 females) with a simple humerus fracture diagnosis, type 1.2.A according to the AO classification, who were divided into two groups. Group 1 was treated with ante-grade intramedullary nailing with distal locking screws inserted with a freehand technique. Group 2 was treated with the intramedullary nail using the Sureshot™ Distal Targeting System. Two intra-operative time parameters were evaluated in both groups: the time needed for the positioning of the distal locking screws and the time of exposure to ionizing radiations during this procedure.

RESULTS

Group 2 showed a lower average distal locking time compared to group 1 (645.48″ vs. 1023.57″) and also a lower average time of exposure to ionizing radiation than in group 1 (4.35″ vs. 28.96″).

CONCLUSION

The Sureshot™ Distal Targeting System has proven to be equally effective when compared to the traditional techniques, with the added benefits of a significant reduction in both surgical time and risk factors related to the exposure to ionizing radiation for all the operating room staff and the patient.

Assessing Wire Navigation Performance in the Operating Room

OBJECTIVE

There are no widely accepted, objective, and reliable tools for measuring surgical skill in the operating room (OR). Ubiquitous video and imaging technology provide opportunities to develop metrics that meet this need. Hip fracture surgery is a promising area in which to develop these measures because hip fractures are common, the surgery is used as a milestone for residents, and it demands technical skill. The study objective is to develop meaningful, objective measures of wire navigation performance in the OR.

DESIGN

Resident surgeons wore a head-mounted video camera while performing surgical open reduction and internal fixation using a dynamic hip screw. Data collected from video included: duration of wire navigation, number of fluoroscopic images, and the degree of intervention by the surgeon׳s supervisor. To determine reliability of these measurements, 4 independent raters performed them for 2 cases. Raters independently measured the tip-apex distance (TAD), which reflects the accuracy of the surgical placement of the wire, on all the 7 cases.

SETTING

University of Iowa Hospitals and Clinics in Iowa City, IA-a public tertiary academic center.

PARTICIPANTS

In total 7 surgeries were performed by 7 different orthopedic residents. All 10 raters were biomedical engineering graduate students.

RESULTS

The standard deviations for anteroposterior, lateral, and combined TAD measurements of the 10 raters were 2.7, 1.9, and 3.7mm, respectively, and interrater reliability produced a Cronbach α of 0.97. The interrater reliability analysis for all 9 video-based measures produced a Cronbach α of 0.99.

CONCLUSIONS

Several video-based metrics were consistent across the 4 video reviewers and are likely to be useful for performance assessment. The TAD measurement was less reliable than previous reports have suggested, but remains a valuable metric of performance. Nonexperts can reliably measure these values and they offer an objective assessment of OR performance.

FLUOROSCOPY DURATION IN ORTHOPEDIC SURGERY

Objective: To ascertain the mean length of radiation emission from fluoroscopic devices during several types of orthopedic surgery and which of these required greater use of radiation. Methods: The times taken to perform sixteen different types of surgery (total of 80 procedures) were measured. At the end of each procedure, the length of time for which fluoroscopy was used directly from the image intensifier was ascertained. Results: The mean time required for fluoroscopy per operation was 61 seconds. The procedures that demanded greatest mean duration of radiation use were bilateral proximal femoral epiphysiodesis (5.1 minutes) and femoral shaft osteosynthesis using a locked intramedullary nail (3.33 min). Conclusion: The mean duration of fluoroscopy use in orthopedic operations was 61 seconds. The procedures using an intramedullary device were the ones that required greatest radiation emission.

Evaluation of occupational and patient radiation doses in orthopedic surgery

This study intends to measure the radiation dose to patients and staff during (i) Dynamic Hip Screw (DHS) and (ii) Dynamic Cannula Screw (DCS) and to evaluate entrance surface Air kerma (ESAK) dose and organ doses and effective doses. Calibrated Thermoluminescence dosimeters (TLD-GR200A) were used. The mean patients' doses were 0.46mGy and 0.07mGy for DHS and DCS procedures, respectively. The mean staff doses at the thyroid and chest were 4.69mGy and 1.21mGy per procedure. The mean organ and effective dose for patients and staff were higher in DHS compared to DCS. Orthopedic surgeons were exposed to unnecessary radiation doses due to the lack of protection measures. The radiation dose per hip procedure is within the safety limit and less than the previous studies.

Pediatric femoral shaft fractures treated with titanium elastic nailing

The objective of this study was to prospectively compare intraoperative fluoroscopy time and clinical and radiological results in pediatric femoral shaft fractures treated with titanium elastic nailing (TEN) using a small-incision, blind-hand reduction vs closed reduction. From February 2008 to December 2009, sixty-eight children were enrolled in the study. Patients were divided into 2 groups: group A comprised 34 patients treated with a small-incision, blind-hand reduction technique and group B comprised 34 patients treated with a closed reduction technique. Operative time, intraoperative fluoroscopy time, fracture union time, and complications were recorded in both groups. Clinical and radiological results were assessed using the TEN scoring system. Mean operative time was 30.5±8.5 in group A and 53.0±15.0 minutes in group B, and mean fluoroscopy time was 28.4±18.5 seconds in group A and 65.0±28.5 seconds in group B. Operative time and fluoroscopy time were significantly longer in group B (P<.001). According to the TEN scoring system, the results were excellent in 31 patients and good in 3 patients in group A and excellent in 29 patients and good in 5 patients in group B. There was no significant difference between the 2 groups in terms of clinical and radiological results. There was also no significant difference in terms of fracture healing time, weight-bearing time, and complications. The small-incision, blind-hand reduction technique provided similar clinical results as closed reduction. This technique could be an alternative to closed reduction because it significantly reduced intraoperative radiation exposure and operative time.

Evaluation of the impact of a system for real-time visualisation of occupational radiation dose rate during fluoroscopically guided procedures

Optimisation of radiological protection for operators working with fluoroscopically guided procedures has to be performed during the procedure, under varying and difficult conditions. The aim of the present study was to evaluate the impact of a system for real-time visualisation of radiation dose rate on optimisation of occupational radiological protection in fluoroscopically guided procedures. Individual radiation dose measurements, using a system for real-time visualisation, were performed in a cardiology laboratory for three cardiologists and ten assisting nurses. Radiation doses collected when the radiation dose rates were not displayed to the staff were compared to radiation doses collected when the radiation dose rates were displayed. When the radiation dose rates were displayed to the staff, one cardiologist and the assisting nurses (as a group) significantly reduced their personal radiation doses. The median radiation dose (Hp(10)) per procedure decreased from 68 to 28 μSv (p = 0.003) for this cardiologist and from 4.3 to 2.5 μSv (p = 0.001) for the assisting nurses. The results of the present study indicate that a system for real-time visualisation of radiation dose rate may have a positive impact on optimisation of occupational radiological protection. In particular, this may affect the behaviour of staff members practising inadequate personal radiological protection.

Olecranon anatomy: Use of a novel proximal interlocking screw for intramedullary nailing, a cadaver study

AIM: To define the optimum safe angle of use for an eccentrically aligned proximal interlocking screw (PIS) for intramedullary nailing (IMN).

METHODS: Thirty-six dry cadaver ulnas were split into two equal pieces sagitally. The following points were identified for each ulna: the deepest point of the incisura olecrani (A), the point where perpendicular lines from A and the ideal IMN entry point (D) are intersected (C) and a point at 3.5 mm (2 mm safety distance from articular surface + 1.5 mm radius of PIS) posterior from point A (B). We calculated the angle of screws inserted from point D through to point B in relation to D-C and B-C. In addition, an eccentrically aligned screw was inserted at a standard 20° through the anterior cortex of the ulna in each bone and the articular surface was observed macroscopically for any damage.

RESULTS: The mean A-C distance was 9.6 mm (mean ± SD, 9.600 ± 0.763 mm), A-B distance was 3.5 mm, C-D distance was 12.500 mm (12.500 ± 1.371 mm) and the mean angle was 25.9° (25.9°± 2.0°). Lack of articular damage was confirmed macroscopically in all bones after the 20.0° eccentrically aligned screws were inserted. Intramedullary nail fixation systems have well known biological and biomechanical advantages for osteosynthesis. However, as well as these well-known advantages, IMN fixation of the ulna has some limitations. Some important limitations are related to the proximal interlocking of the ulna nail. The location of the PIS itself limits the indications for which intramedullary systems can be selected as an implant for the ulna. The new PIS design, where the PIS is aligned 20°eccentrically to the nail body, allows fixing of fractures even at the level of the olecranon without disturbing the joint. It also allows the eccentrically aligned screw to be inserted in any direction except through the proximal radio-ulnar joint. Taking into consideration our results, we now use a 20° eccentrically aligned PIS for all ulnas. In our results, the angle required to insert the PIS was less than 20° for only one bone. However, 0.7° difference corresponds to placement of the screw only 0.2 mm closer to the articular surface. As we assume 2.0 mm to be a safe distance, a placement of the screw 0.2 mm closer to the articular surface may not produce any clinical symptoms.

CONCLUSION: The new PIS may give us the opportunity to interlock IMN without articular damage and confirmation by fluoroscopy if the nail is manufactured with a PIS aligned at a 20.0° fixed angle in relation to the IMN.

Distal locking using an electromagnetic field-guided computer-based real-time system for orthopaedic trauma patients

OBJECTIVES

To compare the efficacy of distal interlocking during intramedullary nailing using a freehand technique versus an electromagnetic field real-time system (EFRTS).

DESIGN

A prospective, randomized controlled trial.

SETTING

Level I academic trauma center.

PATIENTS/PARTICIPANTS

Patients older than 18 years who sustained a femoral or tibial shaft fracture amenable to antegrade intramedullary nailing were prospectively enrolled between August 2010 and November 2011. Exclusion criteria included injuries requiring retrograde nailing and open wounds near the location of the distal interlocks (distal third of the femur, knee, or distal tibia).

INTERVENTION

Each patient had 2 distal interlocking screws placed: one using the freehand method and the other using EFRTS.

MAIN OUTCOME MEASUREMENT

Techniques were compared on procedural time and number of interlocking screw misses. Two time points were measured: time 1 (time to find perfect circles/time from wand placement to drill initiation) and time 2 (drill initiation until completion of interlocking placement).

RESULTS

Twenty-four tibia and 24 femur fractures were studied. EFRTS proved faster at times 1 and 2 (P < 0.0001 and P < 0.0002) and total time (P < 0.0001). This difference was larger for junior residents, though reached statistical significance for senior residents. Senior residents were faster with the freehand technique compared with junior residents (P < 0.004), but the 2 were similar using EFRTS (P = 0.41). The number of misses was higher with free hand compared with EFRTS (P = 0.02).

CONCLUSION

These results suggest that EFRTS is faster than the traditional freehand technique and results in fewer screw misses.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The comparison of freehand fluoroscopic guidance and electromagnetic navigation for distal locking of intramedullary implants

INTRODUCTION

In locking intramedullary nails, the most important problem is to put the distal interlocking screw accurately and quickly with minimum radiation exposure. The purpose of this clinical study was to compare the fluoroscopic time and surgical time required for distal locking with either free-hand fluoroscopic guidance or with an electromagnetic navigation system.

MATERIALS AND METHODS

The study comprised 54 patients with 58 fractures of the lower extremity. The patients were divided in two groups: distal locking with freehand fluoroscopic guidance (group I) and distal locking with electromagnetic navigation (group II). The primary outcome in this study was fluoroscopy time. The secondary outcome was the operative time in distal interlocking.

RESULTS

In group I, the mean operation time was 108 (81-135) min, the mean time for distal interlocking was 18.35 (9-27) min, the total fluoroscopy time was 47.77 (19-74) s, the mean fluoroscopy time during distal interlocking was 18.29 (2-29) s and the mean attempt at number of distal locking for two screws was 9.96 (2-18) times. In group II, the mean operation time was 80.96 (63-100) min, the mean time for distal interlocking was 7.85 (6.5-10) min, the total fluoroscopy time was 22.59 (15-32) s, the mean fluoroscopy time during distal interlocking was 1.62 (0-2) s and the mean attempt number of distal interlocking was 2 (2-2).

CONCLUSION

Fluoroscopy time to achieve equivalent precision is significantly reduced with electromagnetism-based surgical navigation compared with free hand fluoroscopic guidance. Also the operative time is significantly reduced with electromagnetic based navigation.

Radiation-free distal locking of intramedullary nails: evaluation of a new electromagnetic computer-assisted guidance system

Distal locking of intramedullary nails (IMNs) is a difficult part of intramedullary nailing (IMN) that could be time-consuming and expose the surgeon, the surgery personnel and the patient to a considerable amount of radiation as fluoroscopy is usually guiding the procedure. Utilization of electromagnetic fields for that purpose offers an attractive alternative. The SURESHOT™ Distal Targeting System (Smith & Nephew, Inc., Memphis, TN, USA) is a novel commercially available radiation-free aiming system that utilizes computerized electromagnetic field tracking technology for the distal locking of IMNs. In order to evaluate the efficacy of the system we conducted the present study. Nineteen patients (six females-thirteen males, mean age 39.5 years, range 17-85 years) with closed diaphyseal fracture of the femur (eight patients) or the tibia (eleven patients) were treated with IMN using the SURESHOT™ Distal Targeting System for the distal interlocking. All targeting attempts were successful at first try and followed by correct positioning of the screws. Mean time for distal locking of tibial IMNs (two screws) was 219sec (range 200-250sec). Mean time for distal locking of femoral IMNs (two screws) was 249 (range 220-330sec). In the current study the SURESHOT™ Distal Targeting System proved to be accurate, fast and easy to learn.