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

[This corrects the article DOI: 10.1007/s43465-023-01068-1.].

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.

Management of tibial plateau fractures: a fresh review.

Tibial plateau fractures are complex injuries which carry significant morbidity and economic burden. They can present complex geometry depending upon the direction of the force and position of the limb and are often associated with significant soft-tissue injury. While the goals of adequate reduction, stable fixation, and early mobilization remain unchanged, the management of these injuries can be challenging even to experienced orthopaedic surgeons. Lacking consensus, this review aims to provide a summary of current state of orthopaedic practice in the face of tibial plateau fractures. A PubMed search for relevant recent articles as well as a reading of classical articles on tibial plateau fractures was carried out. The focus remained on articles concerned with management modalities and recent advances. A review of some classification systems was also done and included. A great majority of these fractures need operative fixation while respecting the soft tissues. Numerous methods have been reported in the literature including but not limited to plates, screws, external fixators, arthroscopy assisted methods, balloon-cement tibioplasty, or a combination thereof. There is a shortage of randomized controlled trials comparing various operative methods. This article provides a review of various techniques and latest advances made in the management of tibial plateau fractures. The key to achieving optimal functional outcome is using a tailored approach to the individual patient accounting for factors related to the injury pattern, type of host, surgical skills and experience, and local availability of implant devices while taking care of soft tissue. While there is no gold standard, a staged procedure is recommended with early spanning and definitive fixation at later stage by any appropriate methods while respecting the soft tissue, achieving anatomical reduction and adequate fixation and, early rehabilitation.

K-Wire-Based External Fixator for Management of Salter-Harris Type-II Distal Femur Physeal Injury.

We present a case of a 16-year-old male with a Salter-Harris type II physeal slip of the distal femur managed with closed reduction and K wire and clamp-based external fixator. Knee range of motion exercises were initiated after one week. The union was observed at 10 weeks, and implant removal was done on an outpatient basis. At one year follow-up, the patient had good clinical and radiological outcomes. The K-wire-based external fixator frame is an effective fixation method for distal femur physeal slips in older children, providing favorable radiological and functional outcomes.

Top 50 Cited Papers on Tibial Plateau Fracture Management: A Bibliometric Analysis and Review.

Purpose: The orthopaedic surgeons, especially the young budding surgeons should have a well-balanced knowledge of the past evidence as well the current evidence in the literature for the appropriate as well as optimum management of tibial plateau fractures. Bibliometric analysis of the top-cited papers on tibial plateau fracture management can help know their concurrent interests, deficiencies and conflicting issues regarding their management. This study aimed to identify the 50 most cited research articles in tibial plateau research and analyse their characteristics. Methods: We searched the Thompson Reuters Web of Science database for articles relevant to tibial plateau fracture and prepared a list of top 50 cited articles that included original articles and review articles concerning tibial plateau fractures. The included articles were analysed for contributing journals, corresponding author's country, publication year, cumulative citations, annual citations, citation trends over time, level of evidence and a qualitative review. Results: The search strategy resulted in 2263 articles. The top 50 cited articles were published from 1974 to 2014 and belonged to 12 journal sources. There were 47 original articles and 3 review articles. The average citations per article were 126.2, and the annual citations per article were 6.478 per year. The top-cited articles were relevant to the strategies in the management, classification, fracture reduction, articular restoration, types and number of fixation devices, surgical approaches, associated menisco-ligamentous injuries and applicability of bone grafts/substitutes in tibial plateau fractures. Conclusion: The current bibliometric analysis summarises the top-cited evidence concerning tibial plateau fractures and can be a potential resource for reviewing and locating the same. The analysis shows that most top-cited evidence belongs to the year 2000 onwards. Also, recent articles have a higher annual citation rate. A limited number of journals and mostly, western countries have contributed to the top-cited evidence. Whilst the top-cited evidence has touched several aspects of tibial plateau fractures, it is in the form of level IV case series. It needs better prospective evidence to establish sound recommendations. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00932-4.

Recent advances in predicting, preventing, and managing postoperative delirium.

Postoperative delirium (POD) is a major public health problem associated with poor patient outcomes such as increased hospital lengths of stay, loss of functional independence, and higher mortality. Depending on the study, the reported incidence ranges from 5% to 65%, with the highest incidence in hip and cardiac surgery. Anesthesiologists should be familiar with the predisposing and precipitating factors of POD, particularly screening for preoperative cognitive impairment and frailty syndrome. Screening tools, for example, the Mini-Mental State Exam, Mini-Cog, 4 A's test for delirium screening, and Montreal Cognitive Assessment, can be used to assess for cognitive impairment and the Clinical Frailty Scale to assess for frailty syndrome. The Hospital Elder Life Program is the standard prevention protocol that is tried and tested in reducing the incidence of POD. Prehabilitation, lung protective strategies, pharmacologic agents such as ramelteon, a melatonin receptor agonist, glucocorticoids, dexmedetomidine, and non-pharmacologic agents, such as noise reduction strategies and the encouragement of nocturnal sleep, have all led to a decrease in the incidence of POD and are being studied for their efficacy. However, the data are inconclusive to date. Intraoperatively, preventing hypotension and blood pressure swings, ensuring adequate pain control and anesthetic depth, and using age-adjusted minimum alveolar concentration (MAC) titration reduce the incidence of POD. The incidence of POD using regional or general anesthesia is similar. In this narrative review, we will discuss the current understanding of the predictors, pathophysiology, prevention, and management of POD and identify areas of further research.

K Wires or Cannulated Screws for Fixation of Lateral Condyle Fractures in Children: A Systematic Review of Comparative Studies.

Introduction: Lateral condyle fractures in children have been typically been treated operatively using Kirschner wires (K wire) or cannulated screws (CCS); however, a definitive choice of implant remains a matter of debate. This systematic review aims to determine if union and functional outcomes of these fractures are better with screw fixation. Methodology: A search of PubMed, Medline, Cochrane, and Google scholar was performed in March 2021. The results were screened by title and abstract, and relevance and a quality assessment of the data were performed for the articles meeting the inclusion criteria. Articles comparing radiological and functional outcomes of lateral condyle fractures treated with K wires or screws were included for examination. Articles were excluded if they did not compare outcomes of K wires and CCS together, or were in a language other than English, technical notes, case reports, and articles, which describe the use of fixation methods other than K wire or CCS as well as biomechanical studies were also excluded. Risk of bias and quality assessment of included articles were also done. Results: Seven clinical studies were included. 44.4% (n = 4) were retrospective review of records with level III evidence (77.7%, n = 7). Only two included articles had good-quality assessment scores. Union was reported in 85.7% % in K wire group and 99.6% in CCS group. Functional outcomes were not statistically significant between the two groups. Conclusion: Using screws to fix lateral condyle provides better union; however, there is no difference in the functional outcomes and complication rate between the two. Using screws or buried K wires adds the burden of an additional procedure for removal.

Metallosis and Nonunion: A Case Series and Literature Review.

Metallosis, defined as the presence of free metal particles in the tissue, including bone and soft tissue, is a rare phenomenon seen in orthopedic practice. It is more commonly seen in arthroplasty surgeries, but its occurrence in the presence of other metal implants is also well recognized. Multiple hypotheses are suggested to explain the genesis of metallosis, but it is traditionally believed that abnormal contact between the metal surfaces leads to abrasive wear causing the release of metal particles into the surrounding tissue eliciting foreign body reactions from the body's immune system. The consequences can be local effects, which can be asymptomatic soft tissue lesions, or lead to significant osteolysis, tissue necrosis, joint effusion, and large soft tissue masses, causing secondary pathological effects. The systemic distribution of these metal particles can also contribute to the clinical picture. The literature contains multiple case reports of metallosis following arthroplasty surgeries, but there is limited information on metallosis resulting from osteosynthesis of fractures. In this review, we are presenting our experience with a few patients who developed nonunion following the index surgeries and on revision were found to have metallosis as well. It is difficult to postulate whether metallosis was contributory to the nonunion or the other way around or whether the occurrence of nonunion in face of metallosis was a pure coincidence. Additionally, one of our patients had a positive intraoperative culture, further complicating the picture. In addition to the case series, we present a succinct review of the literature on metallosis found in previous studies.

Patient Preferences Regarding Telemedicine to In-person Consultation: A Questionnaire-Based Survey.

Introduction: Telemedicine has been evolving over the last two decades; however, with the advent of the COVID 19 pandemic, its utility and acceptance have drastically increased. Most studies report increasing acceptability and satisfaction rates. This study aimed to assess patient preferences regarding telemedicine to in-person consultations and to attempt to assess the factors driving these preferences. Material and Methods: A questionnaire-based cross-sectional study was conducted for patients who had both teleconsultation and in-person consultation in the orthopedic outpatient. After obtaining consent to participate in the study, the patients were divided into broad clinical categories and responses were recorded regarding the treatment of illness by the doctor and opinions regarding telemedicine. Most questions were in yes/no or a Likert-based questionnaire. Mean, median, percentage and proportions were used for statistical analysis of the data. Results: The study group included 264 patients, with the majority with fractures and dislocations. Most patients (55.7%) were comfortable using the software for teleconsultation, and half the respondents found telemedicine convenient. A large percentage of the study group preferred in-person consultation to teleconsultation (58.7%), and the primary reasons for discontinuing teleconsultation were dissatisfaction during the interaction with the doctor and poor connectivity to telecommunication networks. Conclusion: Telecommunication has high acceptance and satisfaction, but many factors limit its acceptance in developing countries.

The Current Consensus on the Management of Post-traumatic Blisters Among Orthopaedic Surgeons.

Introduction: Post-traumatic blister is often encountered in high-energy injuries and following major limb surgeries. Currently, there is very limited evidence concerning blister management resulting in a lack of comprehensive guidelines for their management. The current survey-based study aims to appraise the current consensus in post-traumatic management among the practising orthopaedic surgeons and compare the same with the evidence in the literature. Materials and Methods: We conducted an online questionnaire-based survey of orthopaedic surgeons concerning post-traumatic blister management practices. The questionnaire mainly focused on antibiotic prophylaxis, local invasive procedures, antiseptics dressings and additional treatment options regarding blister management. Results: A high prevalence (~ 78%) of systemic antibiotics administration was noticed for post-traumatic blister management. Similarly, large section of respondents (66.4%) advocated for either de-roofing or aspiration of blisters. Approximately 42% of respondents preferred sending blister fluid for cultures. More than half of the respondents used some form of local dressing to cover the blister bed to provide a healing environment. Additional opinions mostly included anti-inflammatory and swelling reducing measures. Few respondents also advocated for oral steroids for inflammation control. Conclusion: The limited evidence available in literature could be the potential contributing factor for varying clinical practices for post-traumatic blister management. The general measures to reduce soft-tissue oedema have been supported by the literature. However, the use of systemic antibiotics and steroids has not been supported by the literature and should be avoided unless indicated due to other reasons. Further evidence is required to strengthen the recommendations for post-traumatic blister management.

Effectiveness of Calcium Sulfate and Hydroxyapatite Composite in Collapse Prevention in Osteonecrosis of Femoral Head.

Introduction Calcium-sulfate-hydroxyapatite bioceramics have been widely used as void fillers in bone. However, their effectiveness as void fillers in core decompression for osteonecrosis of the femoral head (ONFH) in preventing femoral head collapse prevention has limited evidence. The current study investigates the effectiveness of calcium-sulfate-hydroxyapatite bioceramics as a void filler in the core decompression procedure for ONFH. Methods We retrospectively reviewed the clinical and radiological records of ONFH patients that underwent core-decompression using either autologous iliac crest cancellous bone graft or calcium-sulfate-hydroxyapatite bioceramic paste as void fillers with at least one-year follow-up. The primary outcome of this study was the radiological progression of collapse in the last available standard anteroposterior (AP) radiographs of the hip. The collapse progression was compared between the two groups based on void fillers. Results This study included patient records with 44 hip joints that underwent core decompression. There were five female and 33 male patients. The mean age was 29.1±6.3 years. The mean follow-up duration was 21.4±3.4 months. No significant differences in collapse progression were observed between the two groups based on void fillers. Conclusion The use of calcium-sulfate-hydroxyapatite as a void filler in core decompress for ONFH is not superior to the autologous cancellous bone in terms of collapse prevention and mechanical support. Further modifications in the core decompression techniques and well-planned prospective studies would help establish sound recommendations.

Pubic Symphysis Osteomyelitis after Bilateral Laproscopic Hernia Repair: A Case Report and Review of Literature.

Introduction: Pubic symphysis osteomyelitis is a rare complication of hernia repair, it is easily mistaken for osteitis pubis (OP) which can lead to a significant delay in diagnosis and prolonged pain for the patient. Case Report: We present the case of a 41-year-old male who presented with complaints of diffuse low back pain, perineal pain for 8 weeks after bilateral laparoscopic hernia repair. The patient was initially considered to have OP and managed however pain did not relieve with treatment. There was tenderness in the ischial tuberosity only. At the time of presentation, X-ray revealed areas of erosion and sclerosis in the pubis with increased inflammatory markers. Magnetic resonance imaging showed an altered marrow signal in the pubic symphysis, edema in the gluteus maximus on the right side, and collection in the peri-vesical space. The patient was started on oral antibiotics for 6 weeks and clinicoradiological improvement was noted. Conclusion: Pubic osteomyelitis and OP show similar clinical presentations with contrasting treatments. Early identification and initiation of appropriate treatment can decrease morbidity and improve outcomes.

Conventional fluoroscopic views are inadequate to predict the Tip Apex Distance and articular clearance of sliding screw devices: A computed tomography-based analysis.

INTRODUCTION: Tip-apex-distance (TAD) has been widely advocated as the index to predict the risk of screw cut out in hip fractures treated with sliding hip screw devices. The fluoroscopic extents of the femoral head can change with the slightest change in the limb position which includes internal and external rotations, adduction and abduction. These changes can affect the visible TAD and articular-clearance of the screw-tip. The purpose of this Computed-tomography(CT) based analysis is to analyze the variations of the radiographically visible articular-clearance and TAD measurements with limb positioning and to determine the appropriate fluoroscopic projections for different screw-positions within the femoral head. MATERIAL AND METHODS: We retrospectively analysed CT studies of twenty healthy proximal femora. Spatial markers simulating screw tips were placed in the different combinations of anteroposterior(AP) and cephalocaudal(CC) positions. Software-based AP and lateral radiographs were developed for each screw position. Additional AP radiographs with femur in internal and external rotation, and lateral radiographs with the femur in adduction and abduction were developed. The variation of TAD and articular-clearance of the screw was measured among these radiographs for individual screw tip positions. RESULTS: Screw tip placed centrally in AP and CC planes position didn't show any significant variation in TAD and articular-clearance with modified AP and lateral radiographs. Significant differences were observed in TAD and articular-clearance values for other screw tip positions. Anteriorly placed screw tips had higher TAD and articular-clearance values with external rotation and similar changes were observed with posteriorly placed tips in internal rotation. Inferiorly placed tips had higher articular-clearance and TAD with limb abduction and similar changes were observed for superiorly placed tips with limb adduction. CONCLUSIONS: For the sliding screws placed in non-central locations, the clearance of the screw tip from the articular margins can not be appropriately estimated with conventional AP and lateral views. Additional views with the limb in internal rotation and external rotation in AP view, and adduction-abduction in lateral view are required to safely place the sliding screw in the femoral head. The limb should be brought to a neutral alignment for the accurate estimation of TAD.

Complete posterior dislocation of fractured lateral condyle of tibia with disruption of proximal tibiofibular joint: Technical note.

Tibial plateau fracture-dislocations are relatively uncommon injuries. They represent instability patterns due to injured collateral ligaments or extensive condylar depression. Medial and lateral subluxations of the fractured fragments represent the majority of these injuries. Posterior dislocations with the tibial plateau fractures are extremely rare injuries. Moreover, isolated posterior dislocations of the tibial condyles with a normally maintained position of the remaining tibia have not been reported in literature. We describe a difficult case scenario in which whole of the articular segment of the lateral condyle of the tibia was separated from its anterolateral rim and completely dislocated posteriorly, with no contact with the lateral condyle of the femur. Besides this, there was a complete disruption of the proximal tibiofibular joint as well. To further add to the problem, the distal pulses in the affected limb had a reduced volume. Stepwise management of all aspects of this injury has been described in this technical note along with a six-month follow-up.

Modified radiographic views to prevent the anterosuperior and posterosuperior bony violation during screw fixation of femoral neck fractures.

INTRODUCTION: The standard anteroposterior and lateral fluoroscopic projections used during femoral neck fracture fixation provide a two-dimensional representation of the cephalocaudal and anteroposterior extents of the femoral neck. The radiographic representation differs from the actual extent of the femoral neck. The anterosuperior (AS) and posterosuperior (PS) surfaces of the femoral neck are at risk of bony breach by the fixation screws and that may get easily missed with standard fluoroscopic views. The current study aims at investigating the special fluoroscopy views, based on the orientation of the AS and PS surface of the femoral neck, that can help in the safe placement of screws near these surfaces without bony breach. METHOD: A computed tomography-based analysis of fifty intact proximal femora was performed. The longitudinal axis of the proximal femoral shaft and the center of the femoral head were aligned along a common horizontal plane. The cephalocaudally constricted zone of the femoral neck was identified along its axis. The surface inclinations of the AS surface and the PS surface at the constricted zone of the femoral neck were measured in relation to the horizontal plane. The mean, standard deviation, overall range, interquartile ranges and gender-based variation of each of the two surface inclinations were measured. RESULTS: The mean surface inclinations of the AS surface and the PS surface with reference to the horizontal plane were 55° ± 7.76° and 123.32° ± 7.88°, respectively. There were no significant side to side and male to female differences. CONCLUSIONS: The modified radiographic views based on the surface inclinations of the AS and the PS surfaces can help in the localization of the critical zones of these surfaces which are at risk of bony breach with screw placement close to the surface. A prior fluoroscopic evaluation of these surfaces before guidewire placement can help in preventing the surface violation.

Lead extrusion ten months after spinal cord stimulator implantation: a case report.

OBJECTIVES: The purpose of this case report is to describe an occurrence of a rare complication of lead extrusion, which was observed 10 months after spinal cord stimulator (SCS) implantation. METHODS: A patient with low back pain and failed back surgery syndrome underwent implantation of a SCS without complications. Ten months after implantation, one SCS lead extruded from her lower back leading to surgical removal of the leads. RESULTS: After identifying the complication of a SCS lead extruding from the patient's back, a surgical revision was performed to remove the SCS leads but retain the implantable pulse generator (IPG) in the gluteal region. During the surgery, it was noted that the anchors were in the appropriate position, sutured and fibrosed to a deep fascial layer. There were no complications from the surgical revision and no infectious process was observed. CONCLUSIONS: We report the occurrence and management of a rare complication of SCS lead extrusion after SCS implantation for failed back surgery syndrome. After recognition, removal of the leads with retention of the IPG was able to effectively resolve the complication. The revising procedure was well tolerated but resulted in the recurrence of the patient's previous low back pain. We believe that knowledge of this case and its management will aid future physicians in the recognition and management of this rare complication of SCS implantation. Furthermore, as there is a paucity of literature discussing the management of lead extrusion after SCS implantation, we hope that this case report will spur additional research on the management of this complication.

Comparison of three low-cost techniques to control fogging of sealed eyewear in a simulated operating room environment: A preliminary analysis.

PURPOSE: In the current COVID pandemic, hermetically sealed eyewear is recommended for safe surgical practices to prevent eye contact with contaminated airborne particles or aerosols. These sealed eyewears definitely reduce the risk of contamination of eyes. However, there is a constant issue of fogging up of the inner surface that prevents good surgical visibility which can impair surgeons' performance and their ability to perform fine tasks, especially in operating rooms with temperature and humidity controlled as per the COVID guidelines. We investigated the effectiveness of surface-modified anti-fog polyethylene terephthalate(PET) films and the application of a detergent-based surfactant liquid, applied to the inner aspect of viewing frame, and addition of filtered vents in the prevention of fogging up of the protective eyewears in a simulated operating room environment. METHODS: Ten volunteer orthopedic surgeons tested three modifications of a poly-hydrocarbon based hermetically sealed eyewear as a) application of a surface-modified anti-fog PET film on the inner aspect of eyewear, b) application of a detergent-based surfactant coating on the inner aspect of the protective eyewear, and c) addition of two filtered vents/holes on each side of the protective eyewear, covered with an N95 mask cutting. The testing was performed while completing a synthetic bone-based surgical task in a simulated operating room environment of 24-26° temperature and humidity between 40 and 70%, for a maximum of 2 h. The duration to the loss of clear visibility (ability to read a newspaper) and workable visibility (ability to perform the surgical task) was recorded for each volunteer. RESULTS: The detergent-based surfactant provided the longest duration of clear visibility (69.3 ± 8.16 min) and the workable visibility was maintained for more than 2 h. The second best durations of clear visibility (31.9 ± 3.75 min) and workable visibility (41.6 ± 5.39 min) were provided by the surface-modified anti-fog PET film. The addition of the filtered vents provided only a marginal improvement in the visibility. CONCLUSION: A detergent-based surfactant coating of the viewing surface provides a simple, inexpensive and effective solution to the problem of fogging of the protective eyewears. Besides this, the workable vision is maintained for a prolonged duration.

Prediction of quadruple hamstring graft diameter for anterior cruciate ligament reconstruction by anthropometric measurements.

BACKGROUND: The literature is scanty regarding the anthropometric predictors on the diameter of quadruple hamstring graft obtained in anterior cruciate ligament (ACL) reconstruction in Indian population. Minimum diameter of the graft for ACL reconstruction should be >7 mm to preclude failure. The objective of this study was to assess the prediction of the hamstring graft diameter by several anthropometric parameters including age, thigh circumference, weight, height and body mass index (BMI). MATERIALS AND METHODS: 46 consecutive patients who had undergone ACL reconstruction by the same surgeon using quadruple hamstring grafts were evaluated. The age, thigh circumference of the normal side, height, weight and BMI were recorded preoperatively and Pearson correlation was done using these parameters with graft diameter measured intraoperatively. Regression analysis in a stepwise manner was undertaken to assess the influence of individual anthropometric parameters on the graft diameter. RESULTS: There were 44 males and 2 females. Mean age was 29.4 years, mean height was 172.6 cm, mean weight was 70.9 kg, mean BMI was 23.8 kg/m(2), mean thigh circumference was 47.1 cm and mean graft diameter was 7.9 mm. There was a positive correlation individually between the thigh circumference and graft diameter obtained (r = 0.8, P < 0.01, n = 46), and between the height and graft diameter (r = 0.8, P < 0.01, n = 46). On the regression analysis thigh circumference and height were found to be significant predictors of graft diameter giving the following equation: Graft diameter (mm) = 0. 079 height (cm) +0.068 thigh circumference (cm) -9.031. CONCLUSION: Preoperatively using the above equation if graft diameter came out to be <7 mm then alternate options of graft material must be kept in mind in order to prevent failure.