Intraoperative C-arm radiation affecting factors and reduction by an intervention program.

BACKGROUND: The increase in the utilization of fluoroscopy during surgical procedures carries with it an inherent increase in the exposure of both patients and surgical staff to ionizing radiation. The purpose of this study was to examine the ability to reduce radiation doses by the implementation of an intervention program targeted at the staff operating the fluoroscopy machinery and attempting to make a behavioral change in its utilization. METHODS: (1) Fluoroscopy technique was optimized after a series of simulation fluoroscopies. (2) A series of lectures was given to all staff operating fluoroscopy equipment (surgeons and x-ray technicians). (3) Directives for the reduction of radiation were included in the preoperative briefing, a sign was displayed next to the fluoroscopy screen, and radiation data was discussed in postoperative conferences. The index procedure chosen for the study was closed reduction and percutaneous fixation of Gartland III supracondylar humerus fractures. Fluoroscopy time and dosage were compared in 43 cases before the intervention program (group A) and in 40 cases after the program (group B). Reduction accuracy was assessed by the Bauman angle, humerocapitellar angle, and rotation index. RESULTS: The mean fluoroscopy time was 122 seconds (6-565) in group A and 54 seconds (1-188) in group B with a P value of 0.001. Radiation emission was 202 (5-1210) millirems in group A and 90 millirems (10-237) in group B (P=0.005). The mean fluoroscopy time for a surgery performed by a resident was 126 seconds (27-431) with 211 (38-766) millirems of radiation. The presence of a senior surgeon reduced these figures to 75 seconds (1-565) (P=0.003) and 127 millirems (5-1210) (P=0.001). The effect of the intervention program was similar regardless of the level of training of the surgical staff. Reduction accuracy and complication rate were no different in the 2 groups. CONCLUSIONS: Radiation exposure is significantly affected by surgical and fluoroscopic techniques and by the surgeons' level of training. Exposure can be decreased significantly by awareness and behavioral modification. LEVEL OF EVIDENCE: Level II therapeutic study.

Correction of lower limb deformities in children with renal osteodystrophy by the Ilizarov method.

BACKGROUND: Children with renal osteodystrophy (ROD) may develop severe angular deformities of the limbs. Various methods, both medical and surgical, have been described for correction of these deformities, but a literature search showed only 1 child previously treated by the Ilizarov method. The purpose of this study was to characterize the deformities found in our group of patients and to describe our experience in treating these patients with the Ilizarov method. METHODS: Correction of angular deformity by the Ilizarov method was performed on 8 limb segments in 5 patients with ROD. Mean age was 14.9 years. Two patients were on hemodialysis, and 3 had functioning kidney grafts. Surgery was deferred until stabilization of metabolic parameters. RESULTS: There was 1 varus and 7 valgus deformities. Preoperative coronal deformity averaged 29 degrees (18-38 degrees). The Ilizarov apparatus was used in all cases. Correction time averaged 23 days (20-28 days). The time from completion of correction to frame removal averaged 71 days (48-113 days). There were no changes in metabolic parameters or frequency of hemodialysis throughout the treatment. Restoration of a normal mechanical axis was achieved in 4 of the 5 patients. One case failed due to intraarticular instability. There were no major complications. Minor complications included pin tract infections, which responded to antibiotic treatment, and premature consolidation in 1 case. Follow-up averaged 6.5 years (1-10 years). The alignment obtained at surgery was maintained in all 4 patients, and they are functional and symptom-free. The patient for whom the surgery failed remains wheelchair-bound. CONCLUSIONS: The Ilizarov method was found to be safe and effective for correction of malalignment due to ROD. Optimization of metabolic parameters is essential before surgery and throughout correction. The procedure is contraindicated in patients with significant intraarticular knee pathology.

Treatment of severe early onset Blount's disease by an intra-articular and a metaphyseal osteotomy using the Taylor Spatial Frame.

PURPOSE: Severe Blount's disease results in a multiplanar deformity of the lower limb. The mechanical axis is disrupted, there is a rotational deformity, and also shortening of the limb. A depression of the medial tibial plateau causes joint incongruity and instability. The purpose of this study is to review the results of treatment addressing all the aspects of the deformity. METHODS: Four patients were treated for severe Blount's disease. The index procedure consisted of a medial tibial plateau elevating osteotomy, a lateral tibial and proximal fibular epiphysiodesis, a proximal tibial metaphyseal osteotomy, and the application of the Taylor Spatial Frame programmed for correction of varus, rotation and shortening, and preemptive lengthening to compensate for growth arrest. RESULTS: Mechanical axis was corrected from a mean 23 degrees (13 degrees -30 degrees ) to 0 degrees in three patients and 6 degrees valgus in 1. Tibias were lengthened by 1-4 cm. At follow-up, the mechanical axis was 0 degrees in two patients and 7 degrees varus in two. The overlengthening was diminishing as planned. CONCLUSIONS: The double osteotomy and Taylor Frame correction was found to be accurate, safe, and effective for multiplanar deformity correction in severe Blount's disease.