Effect of CURES Legislation on Narcotic Prescriptions After Soft-tissue Hand Surgery.

California's Controlled Substance Utilization Review and Evaluation System (CURES) was mandated in 2018 to monitor and limit opiate prescriptions. This study evaluated the effects of this legislation on postoperative opioid prescriptions of patients undergoing soft tissue hand surgery. Patients receiving carpal tunnel release, trigger finger release, and ganglion excisions 18 months prior to and 18 months after CURES were selected. The primary outcome was milligram morphine equivalent (MME) prescribed at the surgical encounter and at first postoperative visit. There were 758 patients in the pre-CURES cohort and 701 patients in the post-CURES cohort. In the pre-CURES cohort, there was 116.9 ± 123.8 MME prescribed post op and 10.2 ± 70.8 at first follow-up, whereas post-CURES had 58.8 ± 68.4 MME and 1.1 ± 14.1 for post-op and first follow-up respectively. Findings of this study indicate state regulations may play a role in reducing narcotic consumption following soft tissue hand surgery. (Journal of Surgical Orthopaedic Advances 33(2):122-124, 2024).

Evolving Effects of the COVID-19 Pandemic on Hip Fracture Outcomes: A Retrospective Comparison of Pre, Early, and Late Pandemic Timepoints.

INTRODUCTION: Hospital systems were strained during the COVID-19 pandemic, and although previous studies have shown that surgical outcomes in healthy hip fracture patients were unaffected in the initial months of the pandemic, subsequent data are limited. This study examined the evolution of hip fracture care throughout the COVID-19 pandemic. METHODS: A retrospective review (level III evidence) was done of surgically treated adult hip fractures at a Level 1 academic trauma center from January 2019 to September 2022, stratified into three groups: pre, early, and late pandemic. Continuous variables were evaluated with the Student t-test and one-way analysis of variance, categorical variables were evaluated with chi-squared, P < 0.05 considered significant. RESULTS: Late pandemic patients remained in the hospital 30.1 hours longer than early pandemic patients and 35.7 hours longer than prepandemic patients (P = 0.03). High-energy fractures decreased in the early pandemic, then increased in late pandemic (P < 0.01). Early pandemic patients experienced more myocardial infarctions (P < 0.01). No significant differences in time to surgery, revision surgery, 90-day mortality, or other adverse events were noted. CONCLUSION: To our knowledge, this is the longest study evaluating hip fracture outcomes throughout the COVID-19 pandemic. These results are indicative of an overburdened regional health system less capable of facilitating patient disposition.

A Look Into How the "Blue Zone" Lifestyle May Affect Patients' Lives Before and After Hip Fracture: A Propensity-Matched Cohort Study.

INTRODUCTION: Hip fractures are life-changing injuries with associated one-year mortality up to 30%. Five locations in the world have been termed "blue zones," where the longevity of the population is markedly higher than that of surrounding areas and there are 10 times more centenarians. The United States has one blue zone (Loma Linda, California), which is believed to be because of the lifestyle of the Seventh-day Adventist population living there. We hypothesized that patients from the blue zone experience low-energy, frailty-driven, osteoporotic hip fractures later in life and an increased postinjury longevity relative to non-blue zone control subjects. METHODS: A review of patients treated for hip fracture between January 2010 and August 2020 from a single institution was conducted. Demographic data were collected, and the end point of mortality was assessed using death registry information, queried in April 2024. Groups were divided into blue zone and non-blue zone. Statistical analysis was conducted with P < 0.05 considered significant. RESULTS: Complete data were available for 1,032 patients. The blue zone cohort sustained low-energy hip fractures 12 years later in life (83.2 versus 71.1, P < 0.01). Propensity score matching was used to account for this difference. After propensity score matching, age, body mass index, American Society of Anesthesiologists score, surgery performed, sex, mechanism, ethnicity, diabetes, chronic obstructive pulmonary disease, CHF, chronic kidney disease grade, dementia, surgical time, and drug/tobacco/marijuana use were similar between groups. Blue zone patients had lower mortality at both 1 and 2 years postoperatively (12% versus 24%, P = 0.03 and 20% versus 33%, P = 0.03, respectively), had more hypertension (76% versus 62%, P = 0.03), reported lower alcohol use (7% versus 20%, P < 0.01), and included more Seventh-day Adventists (64% versus 15%, P < 0.01). CONCLUSION: The blue zone lifestyle affected the onset of frailty and delayed osteoporotic hip fracture by 12 years in this propensity-matched cohort study. Postoperative mortality was also markedly lower in the blue zone cohort.

Pelvic Ring Injuries: Stable or Not?

Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.

Increased Risk of Surgical Field Contamination from Acute Pre-operative Treatment of Pediculosis Capitis (Lice) Infestation - A Case Report of Two Twin Pediatric Patients.

Introduction: Little is known about the perioperative management of Pediculus capitis (lice) infestations, including risk of contamination to the sterile field, whether to delay surgery, and optimal time to treat and/or operate. Case Report: Two identical twin patients presented for elective in situ percutaneous pinning of chronic slipped capital femoral epiphyses. Active pediculosis capitis was noted intraoperatively by the anesthesia team during the first patient's surgery. Meticulous examination of the sterile field at that time demonstrated no organisms or other sources of contamination. The second patient's surgery was delayed to discuss her case with the infectious disease team. Scant literature exists to guide recommendations. Ultimately, a single permethrin treatment immediately before surgery was recommended and followed by our team. After careful prepping and draping, a louse was observed on the sterile field near the planned pin insertion site. The case was immediately canceled and delayed indefinitely. After two additional treatments over the next 4 days, only eggs (but no active insects) were observed in the patient's hair. We elected to proceed to surgery at that time, which concluded without issue. Conclusion: The surgical implications of an active lice infestation are numerous. Administration of antiparasitic medication in the immediate pre-operative period causes increased movement in pediculosis capitis, which may increase risk of sterile field contamination. Elective procedures should be postponed to complete multiple rounds of permethrin. In cases of urgent/emergent surgery, or in which treatment delay is unfeasible, foregoing delousing treatment in the immediate pre-operative period may be recommended.

The Effect of Upper Extremity Tourniquet Time on Postoperative Pain and Opiate Consumption.

BACKGROUND: There is widespread use of pneumatic tourniquet for both upper and lower extremity orthopedic surgeries. Tourniquet use improves visualization, decreases blood loss, and as a result, decreases operative time. Exceeding a certain amount of tourniquet time can cause lasting neuromuscular damage. Orthopedic procedures cause significant pain, and the perioperative narcotic prescriptions after orthopedic surgery have been identified as one of the major contributors to the opioid epidemic. Our aim was to determine whether increasing tourniquet time had a negative impact on immediate postoperative opiate usage in the upper extremity, and to determine other factors associated with increased immediate postoperative opiate usage. METHODS: A retrospective medical record review was performed on patients who underwent volar pleading for fracture fixation between January 2014 and December 2019 at a single institution. Postoperative pain, morphine equivalent dose (MED) usage, and demographic variables were collected. Multivariable analysis was performed, with P < .05 considered significant. RESULTS: Immediate postoperative MED consumed was not correlated with operative time, tourniquet time, preoperative substance usage, or sex. However, postoperative MED consumed was correlated with preoperative narcotic use, high body mass index (BMI), and fracture surgery complexity. CONCLUSIONS: Tourniquet usage under current guidelines does not appear to have an effect on postoperative pain and narcotic usage. Preoperative narcotic usage, BMI, and surgery complexity are significant factors for postoperative opiate consumption.

Do All-terrain or Recreational Off-highway Vehicle Crashes Have a Higher Odds of Amputation?

BACKGROUND: Riding off-road vehicles is associated with the risk of injury to the extremities. There are two main types of four-wheel recreational off-road vehicles: quads or all-terrain vehicles (ATVs), which are essentially four-wheel off-road motorcycles, and recreational off-highway vehicles (ROVs), also colloquially referred to as utility terrain vehicles, which have side-by-side seating, higher maximum speeds, and a roll cage. There are multiple orthopaedic society position statements on ATVs, but none on ROVs. Perhaps this is because the injury patterns and differences between the two vehicles have not been elucidated. QUESTIONS/PURPOSES: (1) What patient, vehicle (ROVs versus ATVs), and injury factors are associated with amputation? (2) What are the anatomic location distributions of fractures and amputations by vehicle type? METHODS: Records of all patients in our hospital's billing system who had both a diagnostic code indicating an accident related to an off-road vehicle and one indicating an extremity or pelvic fracture between February 2014 and January 2020 were screened; this resulted in the identification of 328 patients with fractures resulting from off-road vehicle collisions. A total of 16% (51 of 328) of patients were excluded from the analysis because their injury did not involve either an ATV or an ROV; 277 patients were included in the final analysis. The following variables were collected: age at time of the injury, gender, BMI, vehicle type, Gustilo-Anderson type if applicable, amputation level if applicable, anatomic locations of injuries, ethanol level, and drug screen. ATV crashes accounted for 52% (145 of 277) of patients, and ROV crashes accounted for 48% (132 of 277). Patients from ATV crashes did not differ from those in ROV crashes in terms of mean age (24 ± 16 years versus 24 ± 13 years; p = 0.82), BMI (25 ± 7 kg/m 2 versus 26 ± 6 kg/m 2 ; p = 0.18), or gender (79% [114 of 145] men/boys versus 77% [102 of 132]; p = 0.79). Among patients who had a drug or ethanol screen, there was a higher percent of ATV riders who used marijuana (39% [19 of 49] versus 17% [7 of 42]; p = 0.04), but there were no differences in abnormal blood alcohol screen or abnormal nonmarijuana drug screen; however, these results were available in only about one-third of patients (99 of 277 for ethanol and 91 of 277 for drug screen). Statistical analysis was performed using logistic regression analysis for factors associated with amputation, with p values < 0.05 considered significant. RESULTS: After controlling for differences in demographic factors, the stepwise increase in Gustilo-Anderson grade of open fracture (OR 9.8 [95% CI 3.6 to 27.0]; p < 0.001) and ROV vehicle type (OR 15.7 [95% CI 3.6 to 68.5]; p < 0.001) were both associated with amputation. There was no increase in the odds of amputation associated with age (OR 1.0 [95% CI 0.9 to 1.1]; p = 0.81), gender (OR 1.4 [95% CI 0.3 to 5.8]; p = 0.68), or BMI (OR 1.1 [95% CI 0.9 to 1.2]; p = 0.37). The most frequent ATV fractures occurred in the forearm and wrist (22% [45 of 203]), whereas most ROV injuries occurred through the metacarpals (41% [107 of 262] of fractures and 58% [18 of 31] of amputations). CONCLUSION: ROV crashes are associated with a higher odds of amputation when compared with ATV crashes. Because most ROV injuries were in the forearm and below, this likely occurs when upper extremities are crushed and mangled under the roll cage in rollover ROV crashes. Because of this danger, we urge our orthopaedic societies to either update current ATV position statements to include ROVs or release separate statements on ROVs. LEVEL OF EVIDENCE: Level III, prognostic study.

Reoperation and Perioperative Complications After Surgical Treatment of Cervical Radiculopathy: A Comparison Between Three Procedures.

STUDY DESIGN: A retrospective database study. OBJECTIVE: The purpose of our study was to compare the perioperative complications and reoperation rates after anterior cervical discectomy and fusion (ACDF), cervical disk arthroplasty (CDA), and posterior cervical foraminotomy (PCF) in patients treated for cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical radiculopathy results from compression or irritation of nerve roots in the cervical spine. While most cervical radiculopathy is treated nonoperatively, ACDF, CDA, and PCF are the techniques most commonly used if operative intervention is indicated. There is limited research evaluating the perioperative complications of these surgical techniques. MATERIALS AND METHODS: A retrospective review was performed using the PearlDiver Patient Record Database to identify cases of cervical radiculopathy that underwent ACDF, CDA, or PCF at one or two levels from 2007 to 2016. Perioperative complications and reoperations following each of the procedures were assessed. RESULTS: During the study period, 25,051 patients underwent ACDF, 522 underwent CDA, and 3986 underwent PCF. After propensity score matching, each of the three groups consisted of 507 patients. Surgical site infection rates were highest after PCF (2.17%) compared with ACDF (0.20%) and CDA (0.59%) at 30 days and three months ( P =0.003, P <0.001), respectively. New-onset cervicalgia was highest following ACDF (34.32%) and lowest after PCF (22.88%) at three and six months ( P <0.001 and P =0.003), respectively. Revision surgeries were highest among those who underwent CDA (6.90%) versus ACDF (3.16%) and PCF (3.55%) at six months ( P =0.007). Limb paralysis was significantly higher after PCF compared with CDA and ACDF at six months ( P <0.017). CONCLUSIONS: The rate of surgical site infection was higher in PCF compared with ACDF and CDA. New-onset cervicalgia was higher after ACDF compared with PCF and CDA at short-term follow-up. Revision surgeries were highest among those undergoing CDA and lowest in those undergoing ACDF. LEVEL OF EVIDENCE: 3.

Do Current Stability Scores After MPFL Reconstruction Correlate With Patient Satisfaction Postoperatively?

Background: Patellar dislocation can lead to instability, pain, limited function, and recurrent dislocations. Medial patellofemoral ligament (MPFL) reconstruction leads to favorable patient reported outcomes, but many patients fail to return to previous activity levels. The purpose of this study is to determine how well patients do after MPFL reconstruction and to determine the most important factors for evaluation of patellar instability following MPFL reconstruction. Methods: After IRB approval, a retrospective chart review was performed on all patients who underwent MPFL reconstruction from January 2006 to January 2014 by two board-certified sports orthopaedic surgeons. Patients were then contacted to complete a follow-up questionnaire about satisfaction, functional status, pain, and patellar stability. Patients with at least one-year of follow-up data, a complete data set, and a completed questionnaire were included in the final analysis. Charts of 100 patients were reviewed and 54 patients met all criteria for inclusion in the study. Chi-square analysis, t-tests, and multivariate and univariate logistic regression models were used to estimate the effects of multiple variables on return to activity, satisfaction, and function while controlling for covariates with p<0.05 considered significant. Results: When asked about subluxation, 20% (11/54) reported recurrent patellar subluxation (without re-dislocation). Of the 11 patients who reported re-subluxation, 54% (6/11) reported being highly satisfied (rating of 9-10/10) with the outcome of their knee. Of the 54 patients, 54% (29/54) did not return to previous levels of activity, nevertheless, 31% (9/29) of these 29 patients reported being highly satisfied with the outcome of their knee. Conclusion: Patients report high levels of satisfaction even if they have recurrent instability or are unable to return to prior activity levels. Current scoring systems do not accurately depict patients' post-operative outcomes after MPFL Reconstruction. Level of Evidence: III.

Do Orthopaedic Residency Programs Have the Least Time Between Invitation and Interview?

BACKGROUND: The cost and stress of applying to residency programs are increasing. Planning for interviews with limited lead time can cause additional burden to residency applicants. OBJECTIVE: We sought to determine if the specialty of orthopaedics was affording the same lead time between interview invitation and interview dates as its surgical and medical counterparts. METHODS: Dates for the first interview invitation and last possible interview were gathered for each program in orthopaedic surgery, general surgery, otolaryngology, vascular surgery, plastic surgery, neurological surgery, internal medicine, psychiatry, pediatrics, and family medicine. Interview lead time was calculated for each specialty. Mann-Whitney U and independent sample Kruskal-Wallis tests were used for nonparametric data with P < .05 considered as significant. RESULTS: Orthopaedic surgery lead time is significantly different when compared individually and pairwise to other specialties (P < .05 for all comparisons), with a median lead time of 57 days. The next lowest lead time specialty is otolaryngology with a 70-day lead time. The specialty with the longest is pediatrics (median 106 days). CONCLUSIONS: Residency programs (orthopaedic surgery in particular) vary widely in the amount of lead time given to schedule and attend interviews. The authors propose that interview invitations be extended into mid-October.

Diffuse Recalcitrant Osteomyelitis and Joint Septicemia Because of Bowel Perforation Secondary to Gunshot Injury: A Case Report.

CASE: A previously healthy 22-year-old man was brought into the emergency department after sustaining a low-velocity, civilian gunshot wound to the abdomen that perforated the bowel. Over the next 300 days, he would be admitted and discharged multiple times, requiring a total of 48 debridements, 23 different antimicrobials in 81 unique combinations, and had 18 different microbes cultured from various sites in bone, joint, and blood. Multiorganism bacteremia and fungemia culminated in above-knee amputation because of progression of infection, all in a nonimmunocompromised host. CONCLUSION: Despite following clinical guidelines, patients can still fail evidence-based treatment algorithms. A humbling reminder is that medicine is never one-size-fits-all.

Anatomic Analysis of a Percutaneous Fixation Technique for the Posterior Malleolus Using Posterior-to-Anterior-Directed Cannulated Screws: A Cadaveric Study and Technique Description.

BACKGROUND: Posterior malleolus fractures are traditionally managed with open reduction and internal fixation or percutaneous anterior-to-posterior screws. We present a third option using a percutaneous technique for the placement of posterior-to-anterior-directed screws. An anatomic safety analysis is done using cadaveric specimens. METHODS: Using 15 embalmed specimens (10 F and 5 M), a guidewire was placed using the described technique. The posterolateral ankle was dissected to evaluate for damage to vulnerable structures including the sural nerve, peroneal artery, and flexor hallucis longus/flexor digitorum longus/peroneal/Achilles tendons. The distance from the sural nerve and peroneal artery was measured to the guidewire at its nearest point. The tendons were evaluated for traumatic piercings. RESULTS: The sural nerve had a mean distance to wire of 5.3 mm (range 0 to 12) and the peroneal artery had a mean distance to wire of 5.7 mm (range 2 to 13 mm) with no traumatic piercings of either structure. The flexor hallucis longus/flexor digitorum longus/peroneal/Achilles tendons had no traumatic piercings. CONCLUSION: This percutaneous technique provides a safe alternative to the standard open and traditional percutaneous techniques. It has limited application and is suitable for noncomminuted minimally displaced posterior malleolus fractures and those with fragile tissues where the morbidity of the soft tissue exposure outweighs the benefit of an open reduction.

Should donors who have used marijuana be considered candidates for living kidney donation?

BACKGROUND: The use of marijuana in the USA has been steadily increasing over the last 10 years. This study is the first to investigate the effect of marijuana use by live kidney donors upon outcomes in both donors and recipients. METHODS: Living kidney donor transplants performed between January 2000 and May 2016 in a single academic institution were retrospectively reviewed. Donor and recipient groups were each divided into two groups by donor marijuana usage. Outcomes in donor and recipient groups were compared using t-test, Chi-square and mixed linear analysis (P < 0.05 considered significant). RESULTS: This was 294 living renal donor medical records were reviewed including 31 marijuana-using donors (MUD) and 263 non-MUDs (NMUD). It was 230 living kidney recipient records were reviewed including 27 marijuana kidney recipients (MKRs) and 203 non-MKRs (NMKR). There was no difference in donor or recipient perioperative characteristics or postoperative outcomes based upon donor marijuana use (P > 0.05 for all comparisons). There was no difference in renal function between NMUD and MUD groups and no long-term difference in kidney allograft function between NMKR and MKR groups. CONCLUSIONS: Considering individuals with a history of marijuana use for living kidney donation could increase the donor pool and yield acceptable outcomes.

Virtual Reality Neurorehabilitation for Mobility in Spinal Cord Injury: A Structured Review.

Objective: The goal of this review was to evaluate the evidence regarding the use of virtual reality (VR) therapy for improvement of mobility in patients with spinal cord injury (SCI). Methods: A comprehensive literature search was conducted utilizing PubMed, CINAHL, EMBASE, and PsycINFO databases in April 2018. The phrase "virtual reality" and a combination of "spinal cord injury," "tetraplegia," "quadriplegia," or "paraplegia" were used as search terms. References included selected articles were reviewed as well. Articles were filtered based on the following inclusion criteria: 1) written in English, 2) peer-reviewed, 3) VR used for patients with SCI, and 4) changes in motor function evaluated. Main outcome measurements: Common outcomes of mobility assessment used in the studies included the Functional Reach Test (FRT), Functional Independence Measure (FIM), Limit of Stability (LOS), Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Walking Index for Spinal Cord Injury II (WISCI II) scale. Results: Seven of the nine reviewed articles were case series, while two were randomized, controlled trials. Reviewed literature demonstrated significant benefit in FRT, BBS, gait speed, muscle strength, SCIM, and WISCI-II using VR therapy. Voluntary muscle control improvement was also observed. However, no significant differences were found with regard to finehand motor movement. Conclusion: This literature review demonstrated mostly positive outcomes for the use of VR for SCI rehabilitation but were limited in quality and scope. Larger, multicenter trials are still needed.

How a Donor Nephrectomy Population Can Help Give Perspective to the Effects of Renal Parenchymal Preservation During Partial Nephrectomy.

Introduction: Volume of renal parenchymal loss is known to affect postoperative renal function after partial nephrectomy (PN). We utilize a novel comparison using donor nephrectomy (DN) patients to demonstrate the primary effect parenchymal volume loss plays on postoperative renal function following PN. Materials and Methods: Records of 250 living donor (DN) and 118 PN patients were retrospectively reviewed. Baseline characteristics and preoperative estimated glomerular filtration rate (eGFR)s were recorded. Percent changes in eGFR and incidences of surgically induced chronic kidney disease (CKD-S) in short, intermediate, and long-term postoperative periods were compared. Univariate and multivariate analyses of prognostic factors for development of CKD-S were performed. The PN group was further divided into subgroups with different lengths of warm ischemia time (WIT) and compared with DN patients. Results: At baseline, DN patients were younger, less likely to be male, had lower body mass index, lower American Society of Anesthesiologists, and higher preoperative eGFR (all p < 0.001). At hospital discharge, intermediate follow-up, and latest follow-up, renal function changes in DN and PN groups were -40.5% vs. -3.6%, -34.1% vs. -5.5%, and -33.2% vs. -4.4%, respectively (all p < 0.001). More DN than PN patients developed CKD-S (p < 0.001). DN was a significant risk factor for the development of chronic kidney disease on univariate and multivariate analyses (p < 0.001). On subgroup analysis, both subgroups with WIT 1 to 30 minutes and 31 to 60 minutes had less renal function decline at all time points compared with DN (p < 0.001). Conclusions: Volume of renal parenchyma retained is the dominant driver of postoperative renal function after nephrectomy, compared with all other factors. Surgeons should minimize parenchymal loss during PN to optimize postoperative renal function.

Impact of a Wireless System Upon Verbal Communication in a Simulated Robotic Operating Theater.

OBJECTIVE: To compare the efficacy of communication via the standard Da Vinci Si speaker system with a wireless, hands-free audio system in a prospective blinded study. METHODS: Nine hundred and sixty surgical phrases were spoken in a simulated robotic operating room (OR), including 480 phrases expressed via the Da Vinci Si speakers and 480 phrases expressed through a wireless, hands-free system. Using a dual console robotic system, communication was evaluated. Wireless headsets were given to the console and assistant robotic console surgeons, bedside assistant, anesthesiologist, and circulating nurse. An accurate response was defined as hearing the phrase correctly and transcribing it on a data sheet. The primary outcome was the number of correct phrases recorded during the study and secondary outcomes included subjective clarity and effectiveness of communication reported using a Likert scale. RESULTS: Overall, the wireless, hands-free system increased the accuracy of communication (390/480 [81.3%]) compared to the conventional robotic system (310/480 [64.4%]; P <.001). The bedside assistant, anesthesiologist, and circulating nurse had significantly fewer correct phrases recorded than the assistant robotic console surgeon when using the robotic speakers (P <.05 for all). In contrast, there were no significant differences in the number of correct phrases recorded between different positions when using the wireless system. Subjectively, the wireless system resulted in improved clarity and effectiveness of communication (P = .021; P <.001, respectively). CONCLUSION: Robotic operating systems have intrinsic barriers to effective communication between the surgeon and the rest of the operating room team. Improved communication could reduce surgical errors and improve patient safety.

Conventional vs Computer-Assisted Stereoscopic Ultrasound Needle Guidance for Renal Access: A Randomized Crossover Bench-Top Trial.

PURPOSE: Ultrasound (US) guidance during renal access and mass biopsy reduces radiation exposure, but can be technically challenging. A needle guidance system might simplify these procedures. The purpose of this randomized crossover trial was to compare conventional and computer-assisted US needle guidance systems for renal access and mass biopsy. MATERIALS AND METHODS: Seventy-one subjects were randomized to perform renal access or mass biopsy on a phantom using conventional and computer-assisted US guidance in a crossover study design. The primary outcome was success rate including subgroup analysis by experience level. Secondary outcomes included total procedure time, time to hit target, number of course corrections, and total punctures. In addition, subjective preferences of participants were also collected. RESULTS: Procedure success rate was higher with the computer-assisted US than with conventional US for both novice (98.0% (48/49) vs 81.6% (40/49); p < 0.001) and experienced US users (100% (22/22) vs 81.8% (18/22); p < 0.001). Computer-assisted US significantly shortened the total procedure time (94.0 seconds vs 192.9 seconds; p ≤ 0.001), time required to hit the target (62.5 seconds vs 121.6 seconds; p ≤ 0.001), and the number of course corrections (0.56 vs 2.89; p < 0.001) compared with conventional US. Computer-assisted US did not significantly reduce the number of needle punctures (1.75 vs 2.39; p = 0.132). Seventy-three percent of subjects preferred the computer-assisted US system. CONCLUSION: A computer-assisted needle guidance system increases effective US targeting for renal access and mass biopsy for novice and experienced users.

High-Frequency Dusting Versus Conventional Holmium Laser Lithotripsy for Intrarenal and Ureteral Calculi.

INTRODUCTION: The efficiency of holmium laser lithotripsy for urolithiasis depends upon several factors, including laser pulse energy and frequency and stone composition and retropulsion. This study investigates the complex interplay between these factors and quantifies lithotripsy efficiency using different laser settings in a benchtop kidney and ureter model. MATERIALS AND METHODS: In vitro caliceal and ex vivo porcine ureteral models were constructed. Calcium oxalate monohydrate stones were fragmented using a 200-µm laser fiber. In the caliceal model, stone fragmentation and vaporization rates at settings of 0.6 J/5 Hz, 0.2 J/15 Hz, and 0.2 J/50 Hz were compared. In the ureteral model, fragmentation time, retropulsion rate, fragmentation rate, and fragmented stone weight were compared at settings of 0.6 J/5 Hz and 0.2 J/15 Hz. Retropulsive forces generated at 0.6 J/5 Hz, 0.2 J/15 Hz, and 0.2 J/50 Hz settings were compared. Analysis was performed using Student's t-test and one-way ANOVA. RESULTS: In the caliceal model, the 0.6 J/5 Hz setting fragmented and vaporized stones at a higher rate than the 0.2 J/15 Hz setting (0.072 vs. 0.049 mg/s; p < 0.001). However, when the 0.2 J energy setting was combined with the 50 Hz frequency, the fragmentation rate (0.069 mg/s) was similar to the fragmentation rate at 0.6 J/5 Hz (0.072 mg/s; p = 0.677). In the ureteral model, the 0.6 J/5 Hz setting produced higher fragmentation rates (0.089 vs. 0.049 mg/s; p < 0.001), but resulted in significantly lower fragmented stone weight overall (16.815 vs. 25.485 mg; p = 0.009) due to higher retropulsion rates (0.732 vs. 0.213 mm/s; p < 0.001). Retropulsive forces decreased significantly when pulse energy decreased from 0.6 to 0.2 J (0.907 vs. 0.223 N; p < 0.001). Frequency did not affect retropulsive force at 15 and 50 Hz settings (0.223 vs. 0.288 N; p = 0.509). CONCLUSIONS: Laser lithotripsy of calcium oxalate monohydrate stones in the ureter should be performed using the low-energy, moderate-frequency dusting setting to minimize retropulsion and maximize efficiency. In the renal calix, the low-energy high-frequency setting performed similarly to the high-energy low-frequency setting.

The Impact of Operating Room Noise Upon Communication During Percutaneous Nephrostolithotomy.

OBJECTIVE: Equipment and personnel contribute to the overall noise level in the operating room (OR). This study aims to determine intraoperative noise levels during percutaneous nephrostolithotomy (PCNL) and the effects of this noise upon intraoperative communication. METHODS: A PCNL benchtop model was used to measure intraoperative noise and determine its effect upon communication in three progressively increasing sound environments (baseline ambient noise, ambient noise with PCNL equipment, and ambient noise with both PCNL equipment and music). Five trials with 20 different medical words/phrases were spoken by the surgeon and responses were recorded by the first assistant, anesthesiologist, and circulating nurse. In addition, noise levels during PCNL were compared to common environmental noise levels. RESULTS: In the bench top model, noise levels were 53.49 A-weighted decibels (dBA) with ambient noise, 78.79 dBA with equipment in use, and 81.78 dBA with equipment and music. At the ambient noise level, the first assistant, anesthesiologist, and circulator correctly recorded 100%, 100%, and 96% of the words, respectively. The correct response rate by the subjects decreased to 97% (p = 0.208), 81% (p = 0.012), and 56% (p < 0.001) upon addition of PCNL equipment, and 90% (p = 0.022), 48% (p = 0.002), and 13% (p < 0.001) upon addition of music and PCNL equipment in the first assistant, anesthesiologist, and circulator, respectively. In the simulated OR model, PCNL noise level (81.78 dBA) was comparable to a passing freight train at 30 feet (82.2 dBA, p = 0.44). CONCLUSION: Noise pollution decreases effective intraoperative communication during PCNL. It is important for surgeons to understand the effect noise can have on attempted communication to prevent errors due to miscommunication. In addition, methods to decrease intraoperative noise pollution and improve communication in the OR could improve patient safety and outcomes.