Pinning Of Fractures Research Articles

The Impact of Social Deprivation on Health Care Utilization Patterns Following Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures

BackgroundDisparities in social determinants of health have been linked to worse patient reported outcomes, higher postoperative pain, and increased risk of revision surgery following orthopaedic procedures. Identification of perioperative predictors of healthcare utilization is of particular interest to mitigate cost and improve patient outcomes. The aim of this study is to elucidate the effect of social deprivation levels, using the Area Deprivation Index (ADI), on healthcare utilization following pinning of supracondylar humerus (SCH) fractures. Identifying risk factors for discrepancies in healthcare utilization following SCH fracture fixation can help mitigate unnecessary healthcare spending and improve care of vulnerable patient populations. MethodsThis is a retrospective review of a single institution’s experience with SCH fracture pinning between 2010 and 2023. Demographic variables and healthcare utilization data were recorded within 90 days of surgery. The ADI was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. Results1186 patients from a single level one trauma center were included in this study. The upper, middle, and lower terciles of ADI consisted of 226, 458, and 502 patients, respectively. The most deprived tercile had greater emergency department visitation within 90 days of surgery relative to the least and intermediate deprived terciles (IRR 1.85, 95% CI 1.10-3.08). Identifying as White was an independent risk factor for increased outpatient clinic utilization (IRR 1.17, 95% CI 1.03-1.34). Higher levels of social deprivation were independent risk factors for increased ED visitation. There was no difference in 90-day inpatient readmission rates or telephone/telehealth calls made to the clinic between the least, intermediate, and most deprived patients. ConclusionsThis study begins to shed light on how social determinants of health impact the postoperative care of the pediatric orthopedic patient and which patient populations are the most at-risk for disproportionate resource utilization after pinning of SCH fractures. Understanding these differences may lead to improved patient outcomes while decreasing potentially unnecessary burden on the healthcare system. Level of EvidenceIII; retrospective comparative study Key Concepts1.Social determinants of health impact the postoperative care of the pediatric patient in the setting of supracondylar humerus fractures, more socially deprived patients are at higher risk of postoperative emergency department visits, patient race is shown to be a factor in postoperative clinic utilization.

Implementation of a Hand Training Curriculum in Junior Resident Education: Experience at a Military Orthopedic Residency Program

The American Society for Surgery of the Hand developed the Surgery Training and Educational Platform (STEP) in order to assess essential skills in hand surgery. The American Society for Surgery of the Hand designed modules spanning both osseous and soft tissue skills aimed to be cost effective for the purpose of orthopedic surgical education. The STEP curriculum was adapted and implemented at a single military orthopedic residency program. The following six modules were implemented: (1) depth of plunge, (2) scaphoid pinning, (3) phalangeal fracture pinning, (4) microsurgery, (5) full-thickness skin graft harvest, and (6) wrist arthroscopy. Both first- (PGY1) and second-year (PGY2) residents participated. Scores were calculated according to the original STEP curriculum criteria and were compared with historic data from the previous year. All residents responded to an evaluation questionnaire following the performance of the tasks. The PGY2 cohort outperformed PGY1 cohorts across all modules except for the depth of plunge and scaphoid fixation modules. In the phalangeal pinning module, PGY2s did significantly better when compared with pooled PGY1 performance and their own PGY1 performance (P < .05). In the microsurgery module, PGY2s scored better than pooled PGY1s. In the full-thickness skin grafting module, PGY2s outperformed PGY1s (P < .05). On the post-task evaluation, residents unanimously responded that this was a valuable exercise, but the time required to complete all the modules was significant, similar to that of the previous year survey. The STEP simulation is a cost effective and reliable program to engage residents in hand surgery-related skills. However, adaptations should be encouraged according to institutional resources to provide the most inclusive training platform possible per institutional constraints. The STEP simulation is interpreted by residents as a valuable exercise but requires a significant time commitment that could be a barrier to implementation and regular use. Therapeutic IV.

Highly Adhesive Antimicrobial Coatings for External Fixation Devices.

Pin site infections arise from the use of percutaneous pinning techniques (as seen in skeletal traction, percutaneous fracture pinning, and external fixation for fracture stabilization or complex deformity reconstruction). These sites are niduses for infection because the skin barrier is disrupted, allowing for bacteria to enter a previously privileged area. After external fixation, the rate of pin site infections can reach up to 100%. Following pin site infection, the pin may loosen, causing increased pain (increasing narcotic usage) and decreasing the fixation of the fracture or deformity correction construct. More serious complications include osteomyelitis and deep tissue infections. Due to the morbidity and costs associated with its sequelae, strategies to reduce pin site infections are vital. Current strategies for preventing implant-associated infections include coatings with antibiotics, antimicrobial polymers and peptides, silver, and other antiseptics like chlorhexidine and silver-sulfadiazine. Problems facing the development of antimicrobial coatings on orthopedic implants and, specifically, on pins known as Kirschner wires (or K-wires) include poor adhesion of the drug-eluting layer, which is easily removed by shear forces during the implantation. Development of highly adhesive drug-eluting coatings could therefore lead to improved antimicrobial efficacy of these devices and ultimately reduce the burden of pin site infections. In response to this need, we developed two types of gel coatings: synthetic poly-glycidyl methacrylate-based and natural-chitosan-based. Upon drying, these gel coatings showed strong adhesion to pins and remained undamaged after the application of strong shear forces. We also demonstrated that antibiotics can be incorporated into these gels, and a K-wire with such a coating retained antimicrobial efficacy after drilling into and removal from a bone. Such a coating could be invaluable for K-wires and other orthopedic implants that experience strong shear forces during their implantation.

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.

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. This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees. 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. 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). 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. Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb. DERR1-10.2196/38282.

Pin Fracture in Magnetically Controlled Growing Rods: Influence of the Year of Manufacture.

Magnetically controlled growing rods (MCGRs) have a known issue with fracture of the internal locking pin resulting in early revisions. The manufacturer reported that rods manufactured before March 26, 2015, had a 5% risk of locking pin fracture. Locking pins made after this date are thicker in diameter and of a tougher alloy; their rate of pin fracture is not known. The aim of this study was to better understand the impact of the design changes on the performance of MCGRs. This study involves 46 patients with 76 removed MCGRs. Forty-six rods were manufactured before March 26, 2015, and 30 rods after that date. Clinical and implant data were collected for all MCGRs. Retrieval analysis comprised plain radiographs evaluations, force and elongation testing, and disassembly. The 2 patient groups were statistically comparable. We found that 14 of 27 patients implanted with rods manufactured before March 26, 2015 (group I) had a fracture of their locking pins. Three of the 17 patients with rods manufactured after this date (group II) were also found to have a fractured pin. Retrieved rods collected at our center and made after March 26, 2015, had far fewer locking pin fractures than those made before this date; this may be due to the change in pin design.

Adolescent elbow osteochondral lesions following prior elbow fracture pinning.

Pinning of pediatric elbow fractures has been shown to be a safe procedure with a low complication profile. This study identified patients who underwent cartilage surgery for elbow osteochondral lesions or osteochondritis dissecans who had prior ipsilateral elbow pinning. Records of patients who underwent ipsilateral cartilage surgery for osteochondritis dissecans and prior percutaneous pinning for elbow fractures were identified. Demographics were compiled and the clinical, radiographic, and surgical results were tabulated for patients with at least 1-year of follow-up from initial presentation. In total, 6/52 (11.5%) pediatric patients from 2012 to 2021 who underwent isolated elbow osteochondritis dissecans surgery (mean age at surgery 13.4 ± 1.5 years) had a history of ipsilateral elbow pinning (mean age at surgery 6.9 ± 2.4 years). Of these, five had a history of a supracondylar fracture while one patient sustained a lateral condyle fracture. Overall, three of six patients had mechanical symptoms at presentation and three had abnormal radiographs. All patients underwent pre-operative magnetic resonance imaging and the five patients with an osteochondritis dissecans lesion <1cm2 underwent arthroscopy and microfracture while one with a 4-cm2 lesion underwent open osteochondral allograft transfer. All patients demonstrated improved motion at final follow-up and all patients were able to return to full desired activity following surgery. This study demonstrates that the history of elbow fracture pinning may predispose patients to future elbow chondral injuries in adolescence. Although patients appear to do well following consequent osteochondritis dissecans surgery, patients and parents may be advised of possible association of elbow pinning and elbow osteochondral lesions. III, case-control study.

Evaluation of Percutaneous Pinning of Fractures of the Surgical Neck of the Humerus in Children and Adolescents

Evaluation of Percutaneous Pinning of Fractures of the Surgical Neck of the Humerus in Children and Adolescents

Do Resident Surgical Volumes and Level of Training Correlate with Improved Performance on Psychomotor Skills Tasks: Construct Validity Testing of an ASSH Training Platform (STEP)?

Background:The Surgical Training and Educational Platform (STEP) was developed by the American Society for Surgery of the Hand (ASSH) as a cost-effective set of surgical simulation modules designed to assess critical skills in hand surgery. Previous study demonstrated that STEP can differentiate between novice trainees and board-certified, certificate of added qualification hand surgeons. The purpose of this study was to assess construct validity of STEP by testing its ability to differentiate psychomotor skill level among intermediate trainees.Methods:We evaluated 30 residents from 2 orthopaedic residency programs on 8 modules: (1) lag screw fixation, (2) depth of plunge during bicortical drilling, (3) flexor tendon repair, (4) phalangeal fracture pinning, (5) central axis scaphoid fixation, (6) full-thickness skin graft harvest, (7) microsurgery, and (8) wrist arthroscopy. Spearman correlation was used to correlate total and task-specific scores to case log numbers, months in training, and number of hand surgery rotations.Results:Senior residents had significantly higher mean number of total cases in their total case log (mean difference 96.2, 95% confidence interval [CI] 67.5-124.8, p < 0.01) and number of task-specific cases. Moderate correlation was observed between case log numbers and scaphoid fixation score (rs = 0.423, 95% CI 0.07-0.69) and total score (rs = 0.584, 95% CI 0.25-0.79). Moderate correlation was observed between months in training with: scaphoid fixation (rs = 0.377, 95% CI 0.01-0.66) and microsurgery (rs = 0.483, 95% CI 0.13-0.73); strong correlation was seen with total score (rs = 0.656, 95% CI 0.35-0.83). Moderate correlation with number of hand surgery rotations was observed with tendon repair (rs = 0.362, 95% CI −0.01 to 0.65), skin graft (rs = 0.385, 95% CI 0.01-0.66), wrist arthroscopy (rs = 0.391, 95% CI 0.02-0.67), microsurgery (rs = 0.461, 95% CI 0.10-0.71), and scaphoid fixation (rs = 0.578, 95% CI 0.25-0.79); and strong correlation was seen with total score (rs = 0.670, 95% CI 0.37-0.84).Discussion/Conclusion:The STEP is a validated ASSH education tool that provides a cost-effective simulation for the assessment of fundamental psychomotor skills in hand surgery. Total STEP score correlated with total task-related case volumes as well as months in training and number of hand rotations. Scoring could be modified to improve the fidelity of assessing surgical performance. And, while both time and human resource consuming to perform, administer, and score, this study demonstrates construct validity of STEP in assessing the progression of surgical skill through residency.

Percutaneous Pinning of Fractures of the Surgical Neck of the Humerus in Children and Adolescents

Background: Proximal humerus fractures occur in children of all ages, from newborn babies to teenagers, accounting for about 2% of all childhood fractures, with the highest occurrence among the ages of 11 and 15. Aim of the work: To review and evaluate the outcomes of operative procedure of surgical neck-humerus fractures in children and adolescents using closed reductions and percutaneous pinning. Patients and methods: 20 sufferers enrolled with Proximal Humeral Fracture Displaced in the Orthopedic Surgery Department of the AL Hussein Hospital of the Al-Azhar University Medical Faculty from January 2018 to September 2019 were involved in the current research. Closed reductions and percutaneous Kirscher wires (K-wires) have been used to treat the patients surgically. Ten patients treated with threaded K-wires and other patients with unthreaded K-wires. All patients were examined in the outpatient department using postoperative x-rays to assess healing time and the postoperative range of motion. Results: Regarding complications, group A, 10 (100.0%) of the patients had no complications. Group B 8 (80.0%) of the patients had no complications, 2 (20.0%) of the patients showed a pin-site infection and no malunion was found. Regarding the healing time, 4 (40.0%) of the patients healed in the 1st month and 6 (60.0) of the patients in the 2nd month in both groups. Conclusion: Proximal humeral fractures may be managed using percutaneous pinning, which provides effective reduction and adequate temporary stabilization. This treatment modality was not correlated with any significant complications, like deep infection, avascular necrosis, or neurovascular deficiency.

Establishing Validity of a Comprehensive Hand Surgical Training and Educational Platform (STEP)

The purpose of this study was to develop and perform the initial validation for the Surgical Training and Educational Platform (STEP), a cost-effective psychomotor training and assessment instrument designed to teach and evaluate fundamental skills considered critical to competency in hand surgery. An American Society for Surgery of the Hand (ASSH) taskforce of 13 board-certified hand surgeons developed 8 skills considered fundamental to competency in hand surgery including: (1) lag screw fixation of an oblique fracture, (2) depth of plunge during bicortical drilling, (3) central axis scaphoid fixation, (4) phalangeal fracture pinning, (5) flexor tendon repair, (6) microsurgical suturing, (7) full-thickness skin graft harvest, and (8) wrist arthroscopy. The tasks were developed from commercially available, nonclinical supplies at low cost. The startup cost for the entire system was less than $600 USD, with a cost-per-trainee-assessment of approximately $25 USD. After the tasks were finalized, 2 examiners traveled to 8 sites around the country to evaluate 93 surgeons, including 57 board-certified hand surgeons and 36 first-year orthopedic and plastic surgical residents. Scoring criteria for each task were based on a combination of time and clinically relevant quality metrics. Board-certified hand surgeons significantly outperformed surgical trainees on all 8 tasks, demonstrating that the STEP appropriately differentiates the skill level of expert and novice hand surgeons. The STEP is an effective simulator that encompasses a wide range of fundamental psychomotor skills considered critical to competency in hand surgery. Although the STEP tasks are a valuable surgical training tool, further work is required to evaluate and refine the scoring system prior to using it as a critical evaluation of performance. The STEP simulator is a valuable, validated instrument for resident and fellow education and evaluation in hand surgery outside of the operating room.

Creating an Outpatient, Local Anesthetic Hand Operating Room in a Resource-Constrained Ghanaian Hospital Builds Surgical Capacity and Financial Stability.

Expanding surgical capacity is very difficult in resource-constrained countries. Financial input and additional physical operating room space are needed. The surgical patient volume exists, but the lack of operating room time causes postponement of cases. Hand surgery is particularly important as it improves patient function and allows for a timely return to the workforce after injury. Some hand surgery cases may be performed under local anesthesia with a very basic instrument set in a procedure room. This arrangement eliminates the need and financial burden of an equipped operating room and the need for an anesthesiologist. We hypothesized that performing hand surgery in a simple procedure room by a surgeon with knowledge of adequate local anesthesia could increase hand surgery capacity significantly in a low-income country. This technique has been instituted at Komfo Anokye Teaching Hospital in Kumasi, Ghana, with the use of a single procedure room that was previously used for storage. A surgeon trained in performing wide-awake local anesthesia no tourniquet technique visited Komfo Anokye Teaching Hospital and provided lectures about hand surgery under local anesthesia and evidence-based sterility for 6 years. The number and type of cases performed in the procedure room were recorded for the first 11 months after it opened in 2017. For 11 months, use of this room had increased surgical capacity by 33 cases per month. Patient ages ranged from 2 months to 65 years. There have been 358 total cases performed, 240 of which were hand cases. This included washout of hand wounds (n = 87), tendon repair (n = 54) including a single tendon transfer, fracture pinning (n = 33), amputations (n = 24), trigger finger repair (n = 10), nerve repair (n = 6), congenital hand surgery (n = 4), and other (n = 22). Cost savings per case in the procedure room ranges from 500 cedis (US $100) to 2000 cedis (US $400). The simple procedure room runs more efficiently and is less costly compared with the main operating rooms. Although the case volume has increased surgical capacity significantly, costs to the hospital and patient have decreased. The hospital is reimbursed in a timely fashion for the procedures directly by the patient using this technique. The creation of a single procedure room for wide-awake local anesthesia no tourniquet hand surgery has helped address the issues of inadequate operating room space, time, and expense in resource-constrained Ghana.

A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures.

Simulation-based training is one way to improve basic competence for surgical trainees and thus improve patient safety. Closed reduction and percutaneous pinning of a supracondylar humerus fracture is a common procedure that encompasses many basic orthopaedic skills and has been identified as a residency milestone. Despite this, no quantitative tools exist to help learners attain this basic skill. This study seeks to validate a quantitative, low-cost simulation-based training tool for teaching orthopaedic surgery trainees the fundamentals of fracture stabilization with pins. Two low-cost models were developed with simulated cancellous bone blocks and cortical bone sheets: a pinning agility tool to teach pin placement and redirection, and a low-cost construct stability tool to replicate pinning. A high-cost construct stability tool was cut using a pediatric supracondylar humerus model to simulate pinning a real fracture. Construct stability was assessed by adding weight until ∼1.6 mm of displacement was observed. Participants were tested naively on all 3 models and then completed a training session using only the low-cost models. Performance following training was then assessed and compared with fellowship-trained pediatric orthopaedic surgeons. Participants also rated their preintervention and postintervention confidence, skill, and knowledgeability. A total of 18 novice trainees participated (10 PGY1 and PGY2 orthopaedic surgery residents and 8 medical student members of the orthopaedic surgery interest club), whereas the reference group consisted of 7 orthopaedic surgery attendings. The subjects significantly improved their scores on both the low-cost (P=0.002) and high-cost (P<0.001) construct stability tools after the training with only the low-cost tools. Compared with the attending benchmark, trainee scores improved on the high-fidelity model from 31% preintervention to 86% postintervention and their pinning times decreased by 38%. Trainees reported increased knowledge, skill, and confidence after the intervention (P<0.001). A novel, low-cost simulation model and training session for supracondylar humerus fracture pinning resulted in improved performance in stabilizing a supracondylar humerus model and increased trainee knowledgeability, confidence, and skill. Level II-economic.

A computed tomography study of the fibula: morphology, morphometry, intramedullary anatomy, application prospects on intramedullary nailing.

The intramedullary percutaneous pinning in fractures of the lateral malleolus is a technique of osteosynthesis that can reduce complications of ORIF. Our study describes the morphology and the morphometry of the fibula, in particular intramedullary, so as to specify the best fibular nail features. We conducted a retrospective study on CT acquisitions of fibulae in vivo. We studied total length, and the distal malleolar angle. Regarding intramedullary morphology, six axial study levels were defined. Each level was assigned a morphometric classification (oval, triangular, quadrangular or irregular), and a measure of the diameter of the cavity. The distance between the smaller diameter and the malleolar tip was investigated. We included 50 patients for 97 fibulae. The average age was 66.5years. The irregular morphology type was the most frequently found. The average length was 370.5mm (SD = 18.1; CI 95% [366.9; 374.1]), the average distal malleolar angle was 163.5° (SD = 3.7; CI 95% [162.7; 164.2]). The average minimal intramedullary diameter at malleolus level was 3.2mm (SD = 1.2; CI 95% [3.0; 3.5]), with a minimum size reaching 95.8mm (SD = 13.8; CI 95% [93.0; 98.5]) of the malleolar tip. The analysis of morphological parameters of the fibula, in particular the lateral malleolus and intramedullary morphology is necessary for the design of a morpho-adapted nail. Interpersonal variability must be taken into account by the implant industry to offer nails of suited lengths and diameters.

Assessment of material loss of retrieved magnetically controlled implants for limb lengthening

We aimed to understand wear from the telescopic component of PRECICE nails, which are used for distraction osteogenesis of the femur or tibia. We also aimed to identify any correlation between implant performance and patient factors. This retrieval study involved 11 magnetically controlled intramedullary nails from nine patients who had achieved the targeted leg length. All the nails were assessed macroscopically and microscopically for wear. All implants were radiographed to assess the internal mechanism. A Talyrond 365 (Taylor Hobson, Leicester, UK) roundness measuring machine was used to generate three-dimensional surface maps of the telescopic components to allow for measurement of wear. Visual assessment of all the nails showed evidence of wear from the telescopic component. The radiographs revealed that all the nails had intact internal mechanism and no evidence of fractured pins. The roundness measuring machine showed that the quantity of wear was lowest in the latest design of the PRECICE nail. There was no significant correlation between wear and the two patient factors (duration of the lengthening phase, the time of implantation) included in this study. This study is the first to investigate the performance of the three different designs of the PRECICE system with a focus on wear. We found that the latest design had the best implant performance. We are confident of the continued success of the PRECICE system and reassure surgeons and patients that they are unlikely to encounter problems with the implant related to wear.

Simulation-Based Educational Module Improves Intern and Medical Student Performance of Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures.

Simulation-based education has been integrated into many orthopaedic residency programs to augment traditional teaching models. Here we describe the development and implementation of a combined didactic and simulation-based course for teaching medical students and interns how to properly perform a closed reduction and percutaneous pinning of a pediatric supracondylar humeral fracture. Subjects included in the study were either orthopaedic surgery interns or subinterns at our institution. Subjects all completed a combined didactic and simulation-based course on pediatric supracondylar humeral fractures. The first part of this course was an electronic (e)-learning module that the subjects could complete at home in approximately 40 minutes. The second part of the course was a 20-minute simulation-based skills learning session completed in the simulation center. Subject knowledge of closed reduction and percutaneous pinning of supracondylar humeral fractures was tested using a 30-question, multiple-choice, written test. Surgical skills were tested in the operating room or in a simulated operating room. Subject pre-intervention and post-intervention scores were compared to determine if and how much they had improved. A total of 21 subjects were tested. These subjects significantly improved their scores on both the written, multiple-choice test and skills test after completing the combined didactic and simulation module. Prior to the module, intern and subintern multiple-choice test scores were significantly worse than postgraduate year (PGY)-2 to PGY-5 resident scores (p < 0.01); after completion of the module, there was no significant difference in the multiple-choice test scores. After completing the module, there was no significant difference in skills test scores between interns and PGY-2 to PGY-5 residents. Both tests were validated using the scores obtained from PGY-2 to PGY-5 residents. Our combined didactic and simulation course significantly improved intern and subintern understanding of supracondylar humeral fractures and their ability to perform a closed reduction and percutaneous pinning of these fractures.

Analysing a mechanism of failure in retrieved magnetically controlled spinal rods

PurposeWe aim to describe a mechanism of failure in magnetically controlled growth rods which are used for the correction of the early onset scoliosis.MethodsThis retrieval study involved nine magnetically controlled growth rods, of a single design, revised from five patients for metal staining, progression of scoliosis, swelling, fractured actuator pin, and final fusion. All the retrieved rods were radiographed and assessed macroscopically and microscopically for material loss. Two implants were further analysed using micro-CT scanning and then sectioned to allow examination of the internal mechanism. No funding was obtained to analyse these implants. There were no potential conflicts interests.ResultsPlain radiographs revealed that three out of nine retrieved rods had a fractured pin. All had evidence of surface degradation on the extendable telescopic rod. There was considerable corrosion along the internal mechanism.ConclusionsWe found that a third of the retrieved magnetically controlled growth rods had failed due to pin fracture secondary to corrosion of the internal mechanism. We recommend that surgeons consider that any inability of magnetically controlled growth rods to distract may be due to corrosive debris building up inside the mechanism, thereby preventing normal function.

Cost Savings, Safety, and Patient Satisfication of a Clinic-Based Wide Awake Hand Surgery Practice: A Critical Review of the First 100 Procedures.: Level 2 Evidence

Speakers Bureau: Trimed Inc.(Rhee) Wide awake local anesthesia no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery care while optimizing medical resources. Hand surgery in the clinic setting may result in substantial cost savings and provide a safe alternative to performing similar procedures in the operating room. A prospective cohort study was performed on the first 100 consecutive clinic-based WALANT hand surgery procedures performed at a military medical center from January 2014 to September 2015 by a single hand surgeon. Cost savings analysis was performed by utilizing the Medical Expense & Performance Reporting System (MEPRS), the standard cost accounting system for the military healthcare system (MHS), to compare procedures performed in the clinic versus the operating room during the study period. Utilizing a study-specific questionnaire, patient satisfaction, pain, and perioperative anxiety analyses were performed. The WALANT procedures consisted of carpal tunnel release (CTR, n = 34), A1 pulley release (APR, n = 33), de Quervain release (dQR, n = 4), hardware or foreign body removal (n = 14), phalangeal fracture pin fixation (n = 9), tendon repairs (n = 3), nail horn excisions (n = 2), and extensor carpi ulnar debridement (n = 1). For CTR and APR alone, there was an 85% and 70% cost savings by having the procedures performed in clinic under WALANT compared to the main operating room (OR), respectively. During the 21-month study period, CTR, APR, and dQR performed in the clinic, instead of the OR, amounted to $393,099.53 in cost savings for the MHS. Overall, 94% (62 of 66) of patients stated that they would choose WALANT again for a subsequent procedure. For 71% (47 of 66) of patients, the perioperative pain was less than a dental procedure and the mean anxiety levels (10 being the worst amount of anxiety) before, during, and after the procedures were 2.8 ± 3.4, 2.4 ± 3.2, and 0.4 ± 1.0 respectively. There were 3 complications; however, none were attributable to the WALANT procedure. •A clinic-based WALANT hand surgery program results in considerable cost savings.•Performing clinic-based WALANT hand surgery is safe without any increase in complications attributed to the WALANT procedure.•Patients tolerate the WALANT procedures well with low peri-operative pain and anxiety.•Patient satisfaction is high for clinic-based WALANT hand surgery.

Failure Analysis of a Fractured Pin

Abstract A pin used to hold the side plates together in a conveyor chain system fractured and failed, prompting a metallurgical failure analysis. This case study reviews the analytical steps and conclusions from the study of the failed pin.

Impact Behavior Characterization on Fractured Pins of AISI E52100 Steel

Two fractured pins of impact wrench were evaluated by fractography using scanning electron microscopy. This pneumatic wrench is used to the fabrication of automotive components being characterized by its power and tightening capacity. The important part of the wrench is the pin clutch impact mechanism used to generate high torque. An original pin manufactured with AISI E52100 steel adjusted 2,580 nuts before fracture and a substitute pin of E52100 modified steel with S adjusted 7,095 nuts before failure. Fractographic analysis in both fracture surfaces indicated a ductile-brittle mixed fracture mode. Original pin surface exhibited a granular appearance while substitute pin surface showed fibrous and rough morphology. Precipitation of nearly rounded, elliptical and elongate second – phase particles containing Cr, C and Mn measured as intergranular and transgranular particle density was observed, promoting some brittle failure zones and ductile fracture measured as the volume fraction of grain boundaries and microvoids, respectively. A larger amount of intergranular medium precipitates was found on the original pin which favored the brittle failure among the grain boundaries compared to that of the substitute pin. The ductile fracture by larger transgranular fine particle density which acted as nucleation sites of higher volume fraction of microvoids was found in the substitute pin.

Percutaneous Pinning of Fractures in the Proximal Third of the Proximal Phalanx: Complications and Outcomes

Two common techniques for fixation of extra-articular fractures at the proximal phalanx base are transarticular (across the metacarpophalangeal joint) and extra-articular cross-pinning. The aim of this study was to assess the complications and outcomes of these 2 techniques. Our hypothesis was that transarticular and extra-articular closed reduction and percutaneous pinning of base of proximal phalanx fractures have similar complication rates and outcomes. A retrospective chart review identified 338 patients with base of proximal phalanx fractures. We treated 50 isolated fractures with closed reduction and percutaneous pinning using 1 of 2 techniques: transarticular (25 fractures through the metacarpal head) or extra-articular (25 fractures cross-pinned through the base of the proximal phalanx). Outcome measures included total active motion and complications. We found a substantial overall complication rate in both groups. The mean total active motion for the transarticular group and cross-pinning group was 201° and 198°, respectively. Proximal interphalangeal joint motion was notably affected; nearly half of the patients in each group had flexion loss greater than 20° (average, 27°) at the proximal interphalangeal joint. Nearly a third of patients in both groups had fixed flexion contracture greater than 15° at the proximal interphalangeal joint. There were more secondary procedures in the transarticular group (6) than in the cross-pinning group (2). There was no statistical significance between groups in any of the outcome parameters used. Closed pinning minimizes additional soft tissue injury and allows for early motion, but neither fixation method was superior in terms of the measured parameters. In addition, overall results were not as good as what has been reported in the literature.