Radiation exposure in the treatment of pediatric supracondylar humerus fractures

Value-Driven Pediatric Supracondylar Humerus Fracture Care: Implementing Evidence-Based Practices

Supracondylar humerus fractures are high-volume injuries in children; therefore, value-driven treatment has far-reaching implications for patients and families as well as healthcare systems. Children younger than 5 years can remodel posterior angulation. Most Type IIa fractures will maintain alignment after closed reduction. Many patients with surgical fractures can safely wait for nonemergent fixation. Outpatient surgery is associated with shorter surgical time, lower costs, and fewer return visits to the emergency department with no increase in adverse events. Type III fractures treated the following day do not have higher rates of open reduction, and patients with associated nerve injuries have no difference in recovery time compared with those treated more urgently. Pediatric-trained surgeons generally provide more efficient care (shorter surgical time and less after-hours surgery); however, their outcomes are equivalent to non-pediatric orthopaedic surgeons. Community hospitals have lower costs compared with teaching hospitals; therefore, transferring patients should be avoided when feasible. Postoperative care can be streamlined in uncomplicated cases to minimize radiographs, therapy referrals, and multiple visits. Splinting offers safer, lower cost immobilization over casting. With staffing shortages and an increasingly burdened healthcare system, it is imperative to maximize nonsurgical care, use outpatient facilities, and minimize postoperative requirements without negatively affecting patient outcomes.

Does radiation exposure during pediatric supracondylar humeral fracture surgery change according to the C-arm position? A comparison of two different techniques

INTRODUCTION

In the surgical treatment of supracondylar humeral fractures (SHF), the surgeon has to stand right next to the fluoroscopy device, so it is very important to know how to use it in the most appropriate way to reduce radiation exposure. The aim of this study was to investigate the effect of using C-arm in uniplanar (inverted) and biplanar (standard-horizontal) configurations on (1) the radiation exposure to the surgeon, and (2) surgical time and fluoroscopy exposure time.

MATERIAL AND METHODS

This prospective randomised study was conducted on 20 patients who underwent fluoroscopy during closed reduction and percutaneous pinning for a SHF. In the first configuration, the C-arm was inverted and the image intensifier was used as a surgical table. In the second configuration, the C-arm was used biplanar. The operations were performed by 5 surgeons, with each surgeon using each method only twice. During the operation, to find a value closed to direct radiation exposure measurement was made by attaching a dosimeter to the wrist and scatter radiation exposure was measured by attaching a dosimeter to the neck and waist of the surgeons. The operation time and fluoroscopy exposure time were determined.

RESULTS

The duration of operations performed with the biplanar C-arm position and the fluoroscopy exposure time in operations performed with the uniplanar method were found to be statistically significantly longer (p = 0.001). The measurements on the dosimeter worn on the neck of surgeons were found to be statistically significantly higher while using the uniplanar C-arm configuration (p = 0.001). There was no statistically significant difference between the dosimeter measurements on the wrists and waists of the surgeons and the C-arm configurations (p = 0.820; p = 0.185).

CONCLUSIONS

Although the use of biplanar C-arm has no effect on radiation exposure to the surgeon's wrist, the most important advantages are that the neck area is exposed to less radiation and it shortens the fluoroscopy time so the use of a biplanar C-arm can be recommended.

LEVEL OF EVIDENCE

Level II.

Transfer Validity of Pediatric Supracondylar Humeral Fracture Pin Placement Practice on In-Theater Performance by Orthopedic Trainees Using an Augmented Reality Simulator: Protocol for a Pilot Interventional Cohort Study With a Retrospective Comparator Cohort

BACKGROUND

Supracondylar humeral fractures (SCHF) are a common cause of orthopedic morbidity in pediatric populations across the world. The treatment of this fracture is likely one of the first procedures involving x-ray-guided wire insertion that trainee orthopedic surgeons will encounter in their career. Traditional surgical training methods of "see one, do one, teach one" are reliant on the presence of real-world cases and must be conducted within an operative environment. We have developed an augmented reality simulator that allows trainees to practice this procedure in a radiation-free environment at no extra risk to patients.

OBJECTIVE

This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees.

METHODS

This multicenter, interventional cohort study will involve orthopedic trainees from New Zealand in their first year of advanced training between 2019 and 2023. Advanced trainees with no simulator exposure who were in their first year in 2019-2021 will form the comparator cohort, while those in the years 2022-2023 will receive additional regular simulator training as the intervention cohort. The comparator cohort's performance in pediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a 6-month period. Data on the performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to determine whether additional training with an augmented reality training shows improved real-world surgical outcomes compared to traditional surgical training.

RESULTS

As of February 2022, a total of 8 retrospective comparator trainees have been recruited by email. The study is financially supported through an external grant from the Wishbone Orthopaedic Research Foundation of New Zealand (September 2021) and an internal research grant from the University of Otago (July 2021).

CONCLUSIONS

This protocol has been approved by the University of Otago Health Ethics committee (reference HD21/087), and the study is due for completion in 2024. This protocol may assist other researchers conducting similar studies in the field.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38282.

Extra Lateral Pin or Less Radiation? A Comparison of Two Different Pin Configurations in the Treatment of Supracondylar Humerus Fracture

Background: Closed reduction and percutaneous fixation are the most commonly used methods in the surgical treatment of supracondylar humerus fractures. The pin configuration changes stability and is still controversial. The aim of this study was to investigate the relationship between surgical duration and radiation dose/duration for different pinning fixations. Methods: A total of 48 patients with Gartland type 2, 3, and 4 supracondylar fractures of the humerus were randomized into two groups—2 lateral and 1 medial (2L1M) pin fixation (n = 26) and 1 lateral 1 medial (1L1M) pin fixation (n = 22). A primary assessment was performed regarding surgical duration, radiation duration, and radiation dose. A secondary assessment included clinical outcome, passive range of motion, radiographic measurements, Flynn’s criteria, and complications. Results: There were 26 patients in the first group (2L1M) and 22 patients in the second group (1L1M). There was no statistical difference between the groups regarding age, sex, type of fracture, or Flynn’s criteria. The overall mean surgical duration with 1L1M fixation (30.59 ± 8.72) was statistically lower (p = 0.001) when compared to the 2L1M Kirschner wire K-wire fixation (40.61 ± 8.25). The mean radiation duration was 0.76 ± 0.33 s in the 1L1M K-wire fixation and 1.68 ± 0.55 s in the 2L1M K-wire fixation. The mean radiation dose of the 2L1M K-wire fixation (2.45 ± 1.15 mGy) was higher than that of the 1L1M K-wire fixation (0.55 ± 0.43 mGy) (p = 0.000). Conclusions: The current study shows that although there is no difference between the clinical and radiological outcomes, radiation dose exposure is significantly lower for the 1L1M fixation method.

Dose reduction for minimizing radiation in displaced paediatric supracondylar humerus fractures: single vs. automated pulse mode

Conventional C-arm image intensifiers (CCA) are an essential and indispensable aid in modern orthopaedic surgery. CCAs are defaulted to auto-pulse mode which emit multiple pulses (or bursts) of radiation to obtain optimum image quality. The number of pulses per shot can be configured manually. The purpose of this study is to investigate the efficacy of the single pulse mode of CCA in reducing and fixing paediatric supracondylar humeral fractures (SCHF). A retrospective chart review of 99 paediatric patients who underwent closed reduction and percutaneous pinning of displaced SCHF was performed. Fifty-one consecutive cases operated with auto-pulse mode (group A). Another 48 consecutive cases were operated with the single-pulse mode (group B). Baumann's angle, operative duration and average radiation dose rate were recorded for comparison between both groups. Twenty postpinning images were randomly selected (10 from each group) to study intra- and interobserver reliability. Twelve doctors were recruited and tasked to identify if each X-ray was taken with the auto-pulse or single-pulse mode. This was repeated after 2 weeks. The patients in the auto-pulse mode group had a significantly higher mean radiation dose of 40.4 ± 32.51 cGycm2/min compared to that of 14.8 ± 3.24 cGycm2/min for the single-pulse group (P ≤ 0.001). All patients in both groups had Baumann's angle within normal range of 64-81°. No significant difference was noted in average intraoperative timings between both groups (P = 0.869). In the majority of cases, the doctors were unable to visually differentiate between the modes of CCA used. The single-pulse mode is an excellent alternative to the auto-pulse mode in fixing SCHF. It gives significantly lower radiation without compromising the surgical outcome. Level of evidence: Level III retrospective comparative study.

Time to entry point and distal locking of intramedullary nails: a methodological phantom study comparing biplanar and uniplanar surgical imaging

Background

Intramedullary nailing is the method of choice for diaphyseal fractures of the femur and tibia and is also commonly used to treat trochanteric hip fractures. Perioperative imaging is essential for visualising adequate reduction, achieving an optimal entry point (EP) and performing distal locking (DL) of intramedullary nails. This methodological study aims to compare biplanar and uniplanar imaging in some steps of intramedullary nailing.

Methods

We used a biplanar preassembled imaging device (Biplanar™ 600s, Swemac Imaging) and a uniplanar imaging device (Ziehm Solo FD, Ziehm Imaging) to measure procedural and radiation times for antegrade and retrograde femoral and antegrade tibial nailing in fully soft flexible tissue encased legs with radiopaque sawbones (SKU:1515–7-11, Sawbones Europe, Malmö, Sweden). Four orthopaedic surgeons with different levels of experience performed all procedures in all three phantoms with both image techniques in random order, producing in total 12 EPs and nailings with DL with each imaging device. Time to EP, radiation times, time to DL for both devices and the number of swings of the uniplanar device for the two procedures were measured. Comparisons between the biplanar and uniplanar systems with a paired-samples t-test were conducted.

Results

Using the biplanar device, time to optimal EP was shorter for retrograde femoral (26 s (SD15) vs 35 s (SD13), p = 0.01) and for antegrade tibial nailing (23 s (SD13) vs 49 s (SD24), p = 0.001). No statistically significant differences in time to EP, radiation time or time to DL were found for antegrade femoral nailing. A median of two swings of the uniplanar device was needed to obtain optimal EP for all procedures.

Conclusions

Biplanar imaging slightly but statistically significantly reduced time to EP for retrograde femoral and antegrade tibial nailing in this methodological study comparing biplanar and uniplanar imaging techniques. Biplanar imaging can reduce time and radiation exposure when defining the EP around the knee in intramedullary nailing procedures, but the clinical relevance of these time savings remain to be defined. For antegrade femoral nailing we found no clear benefit with biplanar imaging in the investigated steps of nailing.

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.