How Much Radiation Does a Surgeon’s Brain Receive during Femoral Nailing?

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Impact Science, in response to a recent article in JBJS.

Surgeon exposure to ionizing radiation during C-arm fluoroscopy is common during many orthopaedic procedures, including fracture reduction and fixation-implant positioning. With increased exposure, concern about potential health risks to staff also increases.

A new study in the November 18, 2020 issue of The Journal of Bone & Joint Surgery estimates how much radiation a surgeon’s brain is exposed to while performing short cephalomedullary (SC) nailing over a 40-year career. Ramoutar et al. used two cadaveric specimens (one representing the patient and one head-and-neck specimen representing the surgeon) during a simulated fluoroscopic-guided femoral-nailing procedure.

The dose of radiation to the brain was measured with sensors implanted in the cadaver brain and placed superficially on the skull. Measurements were made with the surgeon specimen set up with different configurations of personal protective equipment (PPE) to test their effectiveness at shielding the brain from radiation.

Ramoutar et al. calculated that the overall extrapolated lifetime dose over 40 working years for surgeons performing 16 SC nailing cases per year without PPE was 2,146 µGy, which is comparable to the radiation exposure during a 1-way flight from London to New York. The authors also found that the use of a thyroid shield was very effective in reducing the radiation exposure to the brain, although the use of additional PPE (e.g., leaded glasses and lead cap) did not add any significant reduction in brain exposure to radiation.

In addition to concluding that the lifetime brain dose of radiation from SC nailing is low, the authors say the findings should encourage surgeons performing this procedure to use thyroid shields. This study also provides a repeatable methodology for future studies investigating brain-radiation doses during other common orthopaedic procedures.

Impact Science is a team of highly specialized subject-area experts (Life Sciences, Physical Sciences, Medicine & Humanities), who collaborate with authors, societies, libraries, universities, and various other stakeholders for services to enhance research impact. Through research engagement and science communication, Impact Science aims at democratizing science by making research-backed content accessible to the world.

 

RCT: “Mini-Navigation” Improves TKA Component Alignment

Alignment is one of the most important factors affecting the longevity of total knee arthroplasty (TKA) prostheses. Among the many available tools for attaining good alignment are new palm-sized, accelerometer-based navigation systems. In the November 18, 2020 issue of The Journal of Bone & Joint Surgery, Minoda et al. deliver robust evidence from a multicenter randomized controlled trial comparing post-TKA coronal alignment with such a “mini-navigation” system versus results using conventional navigation.

The 90 TKAs analyzed (45 in each group) were performed by 8 different surgeons across 5 hospitals in Japan. The primary outcome was the number of tibial-prosthesis alignment outliers, defined as alignment error of >2° relative to neutral, based on weight-bearing radiographs 6 months after surgery. Researchers also compared absolute differences from neutral alignment for both tibial and femoral components, operative time, and complications.

Relative to conventional navigation, the mini-navigation system reduced the number of outliers in tibial alignment and hip-knee-ankle (HKA) angle. In addition, the absolute differences in the coronal alignment of the femoral and tibial prostheses were less in the mini-navigation group. Researchers found no increase in operative time with the portable navigation system, nor was there any observed increase in perioperative complications compared with conventional navigation.

Conversely, there were no significant between-group differences in postoperative Knee Society scores, but the authors note that “another study design with a longer follow-up period” is needed to evaluate the patient-centered clinical effects of prosthetic alignment using portable navigation. Both the authors and Andrew P. Kurmis, FRACS(Ortho), who commented on the study, assert that the true value of navigation systems (mini and full-sized alike) probably lies in higher reproducibility of tibial-component alignment relative to conventional navigation, regardless of the skill and experience of the surgeon.

What’s New in Orthopaedic Rehabilitation 2020

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.

This month, co-author Nitin B. Jain, MD selected the most clinically compelling findings from the >30 studies summarized in the November 18, 2020 “What’s New in Orthopaedic Rehabilitation.”

Hip Fracture
–A retrospective cohort study of >43,000 patients with hip fracture and dementia1 found that more frequent, earlier, and larger amounts of postoperative, in-hospital rehabilitation were associated with better recovery in activities of daily living after discharge.

Rotator Cuff
–A cohort study used propensity-score techniques to compare surgical treatment with nonoperative treatment in 127 patients with symptomatic rotator cuff tears.2 At the 18-month follow-up, patients who underwent operative treatment had significantly better shoulder pain and function outcomes than those who underwent nonoperative treatment.

Anterior Cruciate Ligament (ACL)
–A large prospective multicenter study investigating how rehabilitation factors affect the risk of revision ACL procedures after primary reconstruction yielded good news and bad news about the use of an ACL derotational brace for return to activity. Good: Those using the brace had much-improved KOOS scores at 2 years. Bad: Use of the brace doubled the odds of requiring another surgery within 2 years.

Total Knee Arthroplasty (TKA)
–A randomized controlled trial (RCT) of >300 patients who underwent TKA compared traditional in-home or at-clinic rehabilitation with virtual rehabilitation. The 3 main findings after 12 weeks were as follows:

  • The virtual rehab group had a significantly lower median cost.
  • Virtual rehab was not inferior based on KOOS assessments.
  • There were fewer rehospitalizations in the virtual-rehab group.

Orthobiologics
–An RCT compared the efficacy of an ultrasound-guided injection of leukocyte-rich platelet-rich plasma (PRP), leukocyte-poor PRP, and a control saline injection to treat patellar tendinopathy.3 At the 1-year follow-up, neither PRP formulation was found to be more efficacious than the control injection.

References

  1. Uda K, Matsui H, Fushimi K, Yasunaga H. Intensive in-hospital rehabilitation after hip fracture surgery and activities of daily living in patients with dementia: retrospective analysis of a nationwide inpatient database. Arch Phys Med Rehabil.2019 Dec;100(12):2301-7.
  2. Jain NB, Ayers GD, Fan R, Kuhn JE, Warner JJP, Baumgarten KM, Matzkin E, Higgins LD. Comparative effectiveness of operative versus nonoperative treatment for rotator cuff tears: a propensity score analysis from the ROW cohort. Am J Sports Med.2019 Nov;47(13):3065-72. Epub 2019 Sep 13.
  3. Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L. Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline.

Elite Reviewer Spotlight: Charles Cornell

JBJS is pleased once again to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name:

Charles Cornell, M.D.

Affiliation:

Hospital for Special Surgery, New York, N.Y.

Years in practice: 34 years

How did you begin reviewing for other journals and for JBJS in particular?

I was nominated as a reviewer to JBJS by Al Burstein who was a senior editor.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Read everything you can. Accept every invitation. Set aside time every week for journal work.

Aside from orthopaedic manuscripts, what have you been reading lately?

Novels, nonfiction regarding the history of racism in America

Learn more about the JBJS Elite Reviewers program.

Antibiotic-Laden Cement Lowers TKA-Revision Rates in US Veterans

We recently celebrated Veteran’s Day with the annual tradition of rightfully honoring the men and women who have served in the Armed Forces. After their active duty ends, servicemembers are eligible for care in Veterans Health Administration (VHA) hospitals around the nation. The VHA is a “closed” medical system that affords ample opportunity for population-based research.

In the November 18, 2020 issue of The Journal, Bendich et al. utilized VHA data to compare revision rates after primary total knee arthroplasty (TKA) among veterans treated with antibiotic-laden bone cement (ALBC) or plain cement. Although results of similarly designed studies focused on this question have been equivocal, antibiotic-laden cement seems to be especially effective at preventing infection in higher-risk populations, which is what the US veteran population is considered to be.

The researchers identified 15,972 primary TKAs that were implanted using Palacos bone cement between 2007 and 2015. Approximately 70% (11,231) of those cases used cement mixed with gentamicin, while 30% (4,741) utilized plain bone cement. The authors found similar patient demographics among patients treated with ALBC and those treated with plain cement, but ALBC was used more frequently in patients with higher comorbidity scores.

Overall, utilization of ALBC increased from 50.6% of the cases in 2007 to 69.4% in 2015. At a follow-up of 5 years, ALBC TKAs had a lower all-cause revision rate (5.3%) than plain-cement TKAs (6.7%) and a lower rate of revision for infection (1.9% compared to 2.6%). Even after multivariable adjustments to account for patient, surgical, and hospital factors, these revision-rate differences remained.

Bendich et al. also found that 71 TKAs needed to be implanted with ALBC to avoid 1 revision TKA. With a cost differential of $240 per case for ALBC, I think spending $17,040 ($240 × 71) is more cost-effective than 1 revision TKA, although a formal cost analysis is warranted.

In the interest of full disclosure, as an active-duty US Air Force officer, I am inherently biased, but I feel that no cost is too great to improve the health of our veterans. The authors review arguments against using ALBC, such as a theoretical risk of poor cement mechanical properties and systemic toxicity, but the findings of this study suggest that cement with antibiotics enhances treatment outcomes among these US heroes.

Click here to view the “Author Insight” interview about this study with co-author Alfred Kuo, MD, PhD.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

The Challenges of Complex Revision Elbow Arthroplasty

Lower-extremity joint replacement is quite well-advanced, thanks to a high incidence of disabling osteoarthritis and a 40-plus-year history of development in hip and knee prostheses. Additionally, during the last 5 to 10 years, we have made progress in prosthetic design and reliable surgical techniques for the ankle. In the upper extremity, we have a similar 4-decade development history with anatomic shoulder replacement and now 10-plus years with increasingly reliable reverse total shoulder arthroplasty.

However, techniques for elbow and wrist arthroplasty have been much slower to develop, due to lower incidence of pathology, the unique functional demands on these joints, and prosthetic-design and fixation issues. Still, the Conrad-Morrey family of implants has provided reliable elbow prostheses for more than 20 years. Meanwhile, the indications for elbow arthroplasty have narrowed to inflammatory arthritis and distal humeral fractures and nonunions in patients with lower functional demands. Unfortunately, failure of fixation, infection, and bone resorption do occur after primary elbow arthroplasty; consequently, a small but growing number of patients face revision elbow arthroplasty.

In the November 18, 2020 issue of The Journal, Burnier et al. report the results of revision elbow arthroplasty using a proximal ulnar allograft-prosthetic composite to compensate for missing ulnar bone stock and triceps tendon insufficiency. They clearly explain the surgical technique and report their results among a 10-patient cohort, including details of the 6 cases that required reoperation.

JBJS will continue reporting results of revision joint arthroplasty because members of the orthopaedic community have to manage these very complex cases, and this type of information is helpful to guide treatment decisions and patient expectations. Equally important is the positive impact this information has on further development of surgical techniques and prosthetic designs. Close examination of failure is the fuel for innovative improvement.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Elite Reviewer Spotlight: Dana Mears

JBJS is pleased once again to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name:

Dana C Mears, MD, PhD

Affiliation:

Clinical Professor, University of Pittsburgh Medical Center

Greater Pittsburgh Orthopaedic Associates, Pittsburgh, PA

Years in practice: 45

How did you begin reviewing for other journals and for JBJS in particular?

I was invited by the Editor of each relevant journal to review a manuscript. That event culminated in an invitation to become a regular reviewer.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Such an aspiring reviewer has to be prepared to divert a considerable amount of time and effort to critically evaluate each manuscript in a timely manner.

Aside from orthopaedic manuscripts, what have you been reading lately?

I enjoy reading about decorative gardens and newly developed flowers and shrubs.

Learn more about the JBJS Elite Reviewers program.

Elite Reviewer Spotlight: Nicholas Giori

JBJS is pleased once again to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name:

Nicholas J. Giori M.D., Ph.D.

Affiliation:

Stanford University and VA Palo Alto Health Care System, Palo Alto, CA

Years in practice: 20

How did you begin reviewing for other journals and for JBJS in particular?

I began reviewing for journals when I was a graduate student.  I don’t recall how I specifically became a JBJS reviewer.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Start by stepping back from the details of the article and taking a larger perspective.  What problem are the authors trying to address?  Is the study design appropriate to address the problem or question?  Outline the study in some way and see if it makes overall sense.  Are the authors’ conclusions supported by the results of the study?  After establishing a broad view of the study, you can dive into the details. 

Aside from orthopaedic manuscripts, what have you been reading lately?

I enjoy reading about history as it gives me a perspective on what is happening in today’s world.  My most recent interest has been regarding the history of central Asia.

Learn more about the JBJS Elite Reviewers program.

Dashboard Depicts Surgeon-Level Value of TKA/THA

Remember when a “dashboard” referred to the display just behind a car’s steering wheel? In today’s digital universe, the word has come to mean any number of visual information displays. At the same time, the meaning of the word “value” has narrowed somewhat. In relation to health care, “value” is defined quite precisely as the quality of patient outcomes per dollar spent on healthcare services.

In the November 4, 2020 issue of The Journal of Bone & Joint Surgery, Reilly et al. explain how they created a “value dashboard” for total hip and knee arthroplasty (THA and TKA) at a tertiary-care medical center in New England. The goal: track and display the surgeon-level cost and quality of these procedures against institutional benchmarks to identify opportunities for improving value.

The 7 quality metrics that Reilly et al. used included both clinical and patient-reported outcomes, weighted by surgeons using a modified Delphi process. Average direct costs per surgeon were calculated from the medical center’s billing system, and data were collected over a 15-month period from 2017 to 2018 to ensure at least 1 year of outcomes. Six surgeons were included in the TKA value dashboard, and 5 were included in the THA dashboard.

Relative to the institutional benchmarks:

  • Value for TKA by surgeon ranged from 7% below benchmark to 12% above.
  • Value for THA by surgeon ranged from 12% below benchmark to 7% above.

The dashboard itself (see Figure above) displays quality, cost, and overall value so viewers can see at a glance which metrics are driving the value score for each surgeon, whose procedural volume is also depicted. The authors cite as one limitation of this study the fact that the quality metrics were weighted by local surgeons only, and they say that “ideally the weighting would be informed by a panel of national experts and several stakeholder groups,… including patients.”

Elite Reviewer Spotlight: William Lack

JBJS is pleased once again to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name:

William Lack, MD

Affiliation:

 University of Washington, Seattle, WA

Years in practice: 7 years

How did you begin reviewing for other journals and for JBJS in particular?

I was interested as some of my mentors reviewed for JBJS and I reached out myself to ask if I could be involved.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

I would recommend taking time to thoroughly review each manuscript. I try to avoid any judgements until after I’ve understood the manuscript in its entirety. I attempt to be critical while providing constructive feedback as the goal is to not just determine what is suitable for publication, but to aid the authors in improving their work regardless of JBJS publication. I complete reviews as soon as possible.

Aside from orthopaedic manuscripts, what have you been reading lately?

The Scandinavian crime novel The Man Who Smiled while on a recent vacation, and numerous Roald Dahl books to my 4yo daughter (two to three chapters nightly).

Learn more about the JBJS Elite Reviewers program.