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Mercy Ships Orthopaedic Team Mends More Than Fractures
Author: Pauline Rick, U.S. Media Liaison, Mercy Ships
Jessica is a little girl who usually has a big smile. But even Jessica found it hard to keep smiling when the limb of a tree she was climbing broke, plunging her to the ground causing her arm to break.
For many children, breaking an arm is a part of growing up, and painful wherever they are. However, it does make a difference where they live. If Jessica lived in the UK, Europe or USA, she would likely have been rushed to a nearby hospital. Her arm would have been set properly, and the next day she might have had her friends autographing her cast. In a few months, her arm would be good as ever. However, Jessica lived in Honduras, and her story turned out very different.
Like many who live in developing nations such as Honduras or Africa, Jessica’s family owned no vehicle to take her to a hospital. She had to ride a public bus for two hours and make several changes to get to the nearest hospital. When the accident happened it was too late to catch a bus, so she spent a night in severe pain, with her arm in a makeshift sling. By the time she got medical treatment the next afternoon, her common fracture had become a serious wound. The bone had pierced the skin, and she was becoming feverish.
Jessica ended up spending 20 days in the hospital before her first operation by local surgeons who inserted stainless steel pins. She was sent home for a few months to heal. The entire experience created an extreme economic hardship on the family. On top of medical expenses, her mother needed to stay with her and could not go to her job, thus losing that vital income.
Jessica’s story typifies the plight of the many poverty stricken people in developing nations. The government-run hospitals that are available to them, sometimes known as ‘the poor man’s hospital, are usually severely under funded.
In order to receive treatment, patients must supply their own antibiotics, medical supplies and/or equipment. In the case of an orthopaedic injury requiring surgery, the cost is usually prohibitive for the very poor. Many are sustenance farmers who don’t make enough money to adequately feed and clothe their families. When an accident occurs, they must scraper together money from somewhere. Then the injured often ride a series of local buses. It may take four or more hours to reach the hospital.
It is to this vast need that the Mercy Ships Orthopaedic Team responds. The team works as an arm of Mercy Ships International, a global charity that uses hospital ships to provide free surgeries to the most needy people in developing nations.
In keeping with Mercy Ships general practices, Mercy Ships orthopaedic teams are composed of volunteers who also do free surgeries in developing nations. These well trained surgeons, nurses, physician assistants and other volunteers often use their vacation time to serve in Africa or Central America with Mercy Ships. All are required to have at least two years practice or work in a hospital/medical facility before being accepted to serve on a team for direct medical work. Sometimes they serve onboard a Mercy Ship. On other occasions they work in a hospital, such as the Mario Catarino Rivas Hospital, located in San Pedro Sula, Honduras.
When the Mercy Ships orthopaedic team arrived at this hospital this past November, the beds were already full with patients waiting for surgery who hadn’t been able to pay for the needed implants. Some, like Jessica, were children who had fallen from trees or were hit by cars while crossing the street; others were crippled by birth defects. Many adults were injured in car accidents or with machetes while working in the fields. There was a wide spectrum of injuries and needed operations.
It was here the Mercy Ships orthopaedic team first met Jessica, who had returned to the hospital. Unfortunately, her first surgery by the local surgeon months earlier had not been a success. She had developed an infection in the distal radius. The pins had bent and her wrist was twisted at an abnormal angle and there was a large sequestrum. The infection was still active.
The Mercy Ships team removed the pins, debrided the radius and put on an external fixator. Daily dressing changes were followed by Curettage and Gentamycin laden methyl merthacrylate (bone cement). She was sent home on antibiotics for four weeks. She will return for an iliac bone graft to her forearm. She may need the external fixator for four months but is tolerating it quite well. The team hopes that Jessica will recover full or nearly full use of her arm and hand.
Because of Mercy Ships orthopaedics team, Jessica’s story will likely end well, as will the many others helped by the team. Without their intervention, such patients could only wait for weeks or months as broken bones knitted back together improperly, perhaps rendering the injured arm or leg useless.
During the past six years, Mercy Ships Orthopaedics has been land-based in Central America, collaborating with other nearby Mercy Ship efforts. More than 1,030 surgeries were performed. For 2007, a team looks forward to being based onboard a Mercy Ship in West Africa as well.
Volunteers are vital to the work of Mercy Ships orthopaedic work. They come from across the globe. Some spend a few weeks, others longer periods, but most feel a great satisfaction in what they are able to give.
Nurse Louise Nielsen from Copenhagen, Denmark took a one month leave from her job in a Danish hospital and joined the latest team in Honduras. With her sub-specialty in hip fractures, she was accustomed to orthopaedics, and was able to care for post-operative patients, doing daily dressing changes.
As Louise pushed a cart full of bandages and other supplies from room to room, her warm smile and kind words lifted spirits and encouraged patients. A troupe of merry children with arms in casts and slings often followed her as she did rounds.
Louise commented, “It is great to help the kids, knowing that they are so poor and they have so little. It takes so little to make them happy. To give a coloring book or balloon means so much to them. It’s a great blessing to me.”
In order to carry out these desperately needed operations, Mercy Ships relies heavily on donated equipment and supplies. Dr. James McDaniel, Orthopaedic Consultant for Mercy Ships explained, “We have been blessed with a tremendous supply of usable orthopaedic equipment and materials from a number of manufacturers in the UK and the United States. They understand that we are a Christian humanitarian organization and have been pleased to provide us with relatively new equipment.” In places where there is no equipment, donated equipment that is a couple years old can be of great use. Everything from surgical implants to dressing material is needed as well as some major equipment.
If you would like more information about Mercy Ships orthopaedic teams, or want to donate orthopaedic equipment, finances or to find out about volunteer opportunities, please email Dr. James McDaniel at mcdaniej@mercyships.org or orthopaedics@ioc.mercyships.org
For more information about Mercy Ships go to www.mercyships.org
Accelerating Diagnosis and Treatment of Shoulder Injuries with Ultrasound-based Approaches
Author: Lennard Funk, consultant shoulder and upper limb surgeon, Manchester, UK
Lennard Funk is a consultant shoulder and upper limb surgeon and honorary clinical lecturer at Salford Royal Hospitals and the University of Manchester. He is also an upper limb surgeon and co-director of the Manchester Sports Medicine Clinic, a private practice that he runs together with a sports physician and two other orthopaedic surgeons. He specialises in arthroscopic (keyhole) and minimally invasive surgery of the shoulder and elbow, as well as general upper limb surgery and trauma. His particular interests include shoulder dislocations, frozen shoulder, arthritis, stiff elbows and sports injuries of the shoulder.
Nearly six million people a year in the UK visit a doctor because of shoulder sprain, strain, dislocation or other shoulder problem. The shoulder joint’s mobility makes it prone to injury and frequent overhead movements or sudden trauma can damage tissues within the shoulder, causing pain, tenderness, weakness, instability and limitation of movement in the joint.
The most common shoulder injuries seen at the Manchester Sports Medicine Clinic (MSMC) are impact and contact injuries, usually in rugby players. Chronic shoulder injuries are also very common, specifically in swimmers, overhead athletes such as tennis and badminton players, and wheelchair athletes. Many of these injuries involve damage to the rotator cuff, a sleeve of muscle that surrounds the shoulder joint and is primarily responsible for most shoulder movements. With age, the rotator cuff tendons degenerate and become more prone to acute injury after an impact. It is currently believed that it is better to repair rotator cuff tears as soon as possible in order to maximise restoration of function.
Ultrasound is a particularly useful imaging tool when examining muscle and tendon injuries, particularly of the shoulder. By performing ‘office’ shoulder ultrasound during clinical examinations, patients can be instantly scanned at the first clinic appointment, providing an immediate, one-stop diagnosis and assessment that allows quicker treatment and recovery. It also helps surgeons to plan their patient management, and reduces costs, such as those incurred by a radiology report, by the patient taking additional days off work and the cost of clinicians’ time. Traditionally, ultrasound of the shoulder has been carried out by radiologists in the UK and USA, although in mainland Europe it has been done by surgeons and clinicians. However, recent advances in ultrasound technology, particularly the development of small, portable ultrasound instruments with rapidly improving resolutions, and the increasing awareness and availability of training courses, have made the approach more accessible for clinicians.
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| Figure 1: Ultrasound scans of full thickness rotator cuff tear (supraspinatus) |
Ultrasound helps to diagnose a number of rotator cuff pathologies in the shoulder, especially complete rotator cuff tears, which can be well visualised (Fig 1). Rapid assessment and diagnosis of these injuries is critical, since rotator cuff tears generally get bigger with time, so the longer a patient waits for repair, the more difficult the surgery might be and the longer the projected recovery time. Direct signs of complete tears include flattening of the superficial border of the tendon (the normal tendon is convex); a hypoechoic zone separating the tendon edges; absence of the normal tendon, replaced by a thin hypoechoic line representing the hypertrophic bursa surrounding the greater tuberosity; and flattening of the tendon in response to a compression test (the intact cuff cannot be compressed). A number of indirect signs of rotator cuff tears can also be seen, such as effusion around the long head of the biceps tendon; double effusion where joint effusion is seen around the biceps tendon and subacromial subdeltoid bursitis; deltoid herniation, where the deltoid muscle bulges deeply into the gap of the rotator cuff; and muscle atrophy. Partial rotator cuff tears can also be depicted with ultrasound, but the accuracy is lower than that for complete tears. An audit of the MSMC’s ultrasound use in 2006 demonstrated 92 per cent sensitivity for complete rotator cuff tears and 86 per cent sensitivity for partial tears, in 64 patients.
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| Figure 2: Ultrasound scans of intact rotator cuff six months post-repair |
Ultrasound can also detect calcifications in the rotator cuff. Although these are almost always seen by x-ray, they can be missed due to their location or the direction of the x-ray beam. Furthermore, visualising the appearance of calcifications using ultrasound can predict their symptomatology. For example, long and thin calcifications are often asymptomatic, while thick and rounded or irregular calcifications give rise to symptoms. The amount of posterior attenuation can also predict the calcification’s hardness, which is useful when arthroscopic removal of the calcium deposits is being considered for treatment. Ultrasound-guided barbotage can also be used to treat the problem, where a needle is inserted to aspirate the calcium while scanning the area by ultrasound. Subacromial bursitis can also be seen with ultrasound when the bursa is more than 2 mm thick (or clearly thicker than that of the uninjured shoulder) and, again, ultrasound is particularly useful for guiding injections such as anti-inflammatory treatments into the area.
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| Figure 3: SonoSite MicroMaxx ultrasound system |
The MSMC currently uses three different hand-carried ultrasound machines, the SonoSite MicroMaxx®, TITAN® and 180 PLUS™ ultrasound systems with a 38 mm linear array transducer. The portability of these systems combined with their long-life rechargeable batteries make them easy to transfer between rooms and patient cubicles. The speed with which the systems start up and shut down and ease of use are also important, as well as certain functions such as measurement tools and the ability to save images and videos from scans with accompanying patient data.
The MSMC was one of the first places in the UK to acquire the MicroMaxx ultrasound system, which is the highest resolution portable ultrasound machine on the market. Its new features allow quantitative measurement, enhanced image quality and versatility in a compact and lightweight device. When a patient presents with a suspected rotator cuff tear, examining the patient with the MicroMaxx ultrasound system and making a diagnosis literally adds just three to
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| Figure 4: Lennard Funk |
five minutes to the physical examination. A quick pre-surgical scan instantly shows whether or not there is a tear to the cuff, and how big it is, which is all that is initially required to plan management of the patient’s injury. If additional information is needed then patients are sent to a musculoskeletal radiologist with greater skill and higher resolution machines to provide the necessary details.
A number of orthopaedic ultrasound training courses are available for clinicians, including courses specialising in shoulder ultrasound, which are designed for participants to gain hands-on scanning experience, with plenty of opportunity to practise using the instruments and get a feel for the procedures. For more information on the use of office ultrasound for the shoulder see the Education section of www.shoulderdoc.co.uk.
Useful web links:
www.shoulderdoc.co.uk
www.sonosite.com
www.sonositeusers.com
www.sportsmedclinic.com
© 2006 kdm communications limited
Power Tools In Orthopaedic Surgery
Author: Satish Kale
Introduction
Power tools form the backbone of modern orthopaedic surgical procedures. Power tools have undergone many improvisations and modifications in the past two decades and have improved tremendously in their functionality and versatility.
Orthopaedic cutting tools often receive little medical or even engineering attention beyond the considerations of size and shape. Medical power tools are unfortunately a replica of those used in the metal cutting industry and have evolved as “smaller powered version” of the same. The machining techniques and manufacturing technology deployed for these medical instrumentation are frequently modeled after the these industrial designs. This ‘off-the-shelf ‘ information is then applied to the requirements of a particular orthopaedic application, saving time and allowing more effort to be spent on improving implant performance.
Optimum characteristics of cutting tools
1. Exhaust pathway for bone shavings and metal debris
Shavings produced by a fluted face-cutting tool follow a tortuous path for escape. Following the action of the instrument they must make a right angle turn, then follow a long and narrow channel before clearing the tool. Additional torque and thrust that must be applied to maintain cutting action and to compensate for the power required to push the shavings outside the cavity. The heat produced as a by-product of this inefficiency can also cause thermal necrosis of bone and delay healing.
In contrast, a rotary planar tool has a short and direct flow path that doesn’t create the problems described above. Torque, thrust and heat are reduced as a result with lesser damage to biology and improved chance of healing.
2. Proper cutting edge geometry
Cutting edges intended for metal cutting must be very strong. The high tensile strength of metal requires a blunt angle at the cutting edge in order to resist the high forces generated during cutting. Since bone has a much lower tensile strength than typical metals, cutting edges intended for bone can have a much narrower angle and, as a result, will cut with less force and heat.
3. Sharp, burr-free cutting edges.
4. Metallurgy
The tool’s ability to retain a sharp cutting edge hinges on various factors. Hardness is only one parameter. The other is corrosion-resistance.
What characteristics should we look for in selecting power tools?
- Power
- Simplicity
- Versatility
- Customized Performance
- Standardization
Core power tools in Orthopaedics are:
- Drill Systems
- Bone saws
- Burrs
Common power accessories used are:
- Power Pulse Lavage systems
- Cast cutters
Drill Systems
Drill systems are classified and selected on the basis of use in small/large bone surgery and based on specific applications like orthopaedics, neurosurgery or maxillo-facial surgical applications.
Various parameters considered are:
- Speed : available from 10,000 – 95,000 rpm
- Torque: Ideal is around 2.5 inches/oz.
- Debris channeling troughs: rotary plane type
- Size
- Weight
- Versatility and attachment combinations possible
- Reversibility of directions for drilling
- Heat profile
- Duty cycle
- Flexibility – Flexible or rigid
- Design of the instrument – ergonomics
- Throttled or throttle-less
- Teeth configuration – diamond tooth, serrated etc.
- Autoclavable options
- Low or high profile
Saws
Various characteristics determine saw selection.
They are:
- Power Source: Pneumatic, Battery operated or Electric
- Positions of blades possible
- Compatibility with different selections of blades and makes
- Compatibility with other attachments
- Throttled or throttle-less
- Gear ratio – 5:1 is optimum
Various specifications available are:
Micro - sagittal saw: 0-25,000 cycles per minute (cpm)
Throttle controlled
90-110 pounds per square inch (psi)
Micro- oscillating saw: 0-35,000 cpm
Throttle controlled
90-110 psi
Micro- reciprocating saw: 0-22,000 cpm
Throttle controlled
90-110 psi
Pneumatic extended oscillating saw: 0-35,000 cpm
Burrs
Burr functionality is determined by ball-tip design and configuration. Several designs are available depending on the procedure for which the burr may be required.
Some configurations are:
- Barrel Tip Carbide
- Cross cut fissures
- End/Side cut carbide
- Lindemann Carbide
- Round cutting carbide
- Round diamonds
- Round end carbide
- Shannon 44, stainless
- Burr selection especially depends on application whether orthopaedic, neurosurgical or maxillofacial.
Power Pulse Lavage System
What to look for?
- A non-clogging design
- Fracture resistant spray stem
- Non-brittle suction tip
- PVC-free construction
- Ergonomically designed hand press
- Non-kinking hose preferably polyurethane
- Variable speed trigger
- Suction pressure: not exceeding 100 psi.
Orthopaedic Cast Cutter
Requirements:
- Balance between weight and power to reduce user fatigue
- Ergonomically designed for the plaster room technicians for prolonged use
- Low noise
- Light weight
- Multi-speed control
- What are the risks to the orthopaedic surgeon from using power tools or vibrating machinery?
1. Risk from vibrating power tools:
According to studies by researchers Roberts S, Ashcroft G et al, orthopaedic surgeons are a unique group within the medical profession using vibrating hand-held air and battery powered tools in the regular course of their work. The vibration transmitted to the hand and upper limb by prolonged operation of vibrating tools such as orthopaedic saws can result in the disease known as Hand-Arm Vibration Syndrome (HAVS) in which individuals may complain of white finger, numbness or muscle and joint problems.
The results of their study shown are an eye-opener. Orthopaedic surgeons showed a significant excess of upper limb neurological symptoms related to exposure to the use of battery and air powered tools and peripheral nerve abnormalities were identified in the test group. This study confirms the possibility that orthopaedic surgeons may be a group at risk of developing the neurological and musculoskeletal symptoms of HAVS.
2. Risks from noise exposure in the orthopaedic operating theatre
Surgeons working in orthopedic operating theatres are exposed to significant noise pollution due to the use of powered instruments. This may carry a risk of noise-induced hearing loss. A study by Hamish Love attempted to quantify this noise exposure and establish whether this breaches occupational health guidelines for workplace noise exposure. He concluded that the overall total noise dose during orthopaedic surgery was acceptable but orthopaedic surgeons experience brief periods of noise exposure in excess of stipulated guidelines. This carries a significant, but unquantified risk for noise-induced hearing loss.
3. Risks from surgical smoke and aerosols generated by power tools
Surgical smoke is typically produced during procedures utilizing power equipment, lasers and other electrosurgical instrumentation. Aerosolized particles are also created by the mechanical action of surgical instruments like bone drills and saws. In one study, it was shown that relatively large concentrations of aerosol were produced in hip replacement procedures, and that a large fraction of the particles in that aerosol were in the respirable size range.
An important questions that is yet to be answered is whether operating personnel can be infected by a blood aerosol containing a bloodborne pathogen such as HIV or HBV. No documented cases of human infection have occurred through this route, but smoke or aerosols produced when powered surgical instruments were used on cell cultures infected with HIV have resulted in other cell cultures becoming infected.
Ergonomics Of Power Tools
Power tools should be used wherever feasible. Motor power is better than muscle power. Yet design considerations and surgeon comfort and awareness both, are equally important towards delivering a good result and avoiding operator and equipment breakdown.
What Design Characteristics Need Be Considered In Their Selection?
- Span: Recommended maximum distance between 2 handles of a span type tool is 3.5 inches for men and 3.12 inches for women.
- Curve: The curve of the handle should not be greater than 0.5 inches over its length.
- Diameter: Optimum diameter is dependant on hand size, grip required and task repetitions with the tool.Although in some cases, a larger handle decreases the forces to the small joints of the hand, they may require the hand to utilize muscle groups for which the Motor cortex in our nervous system may not be ideally suited.
- Length: Minimum handle length for any tool is 4 inches and for tools used with gloves, 0.5 inches is added.
- Shape: The shape of the handle should allow the forces to be distributed over as large an area as possible.
- Handle Characteristics: The pressure of the handle should be borne over fat pads of hands avoiding mechanical stresses. Also handles with grooves often do not fit the shape and size of the users hands and thus may place pressure on the delicate structures of the hands. Non-grooved handles may actually be better ergonomically.
- Phalyngeal ends: These should prevent hands from sliding onto dangerous parts of tools that may be either hot or sharp. They should minimize need for tight pinching or grasping.
- Texture: Adequate friction helps to avoid fatigue. Rubber handles provide more friction for a good grip and reduce pressure overall.
- Vibrations: No more than 30 minutes of direct exposure to vibrating tools is recommended at a stretch and only at particular frequencies deemed safe.
Guidelines For The Surgeon
The National Institute for Occupational Safety and Health has researched and has developed many helpful guidelines for hand tool use to minimize occupational hazards.
- The wrists should be kept straight as extremes of positions worsens fatigue and may give rise to carpal tunnel syndromes or overuse injuries. If you need to use the tool at an angle twist the tool or assembly keeping the wrist neutral at all times.
- Avoid immobility when using heavy power equipment. Battery operated tools are lighter and versatile and preferred over the electric or pneumatic types. This avoids neck, back and other musculoskeletal pain syndromes.
- Take frequent breaks when using vibrating equipment like the plaster saws or blunt drills. Prolonged pressure on the palms from these instruments can cause interruption of blood supply and interrupt nerve function.
- Use tools needing forceful gripping or handling and do not use instrumentation requiring stresses on the fingers.
- Beware of instruments which are frequently heat up, are too sharp or have pincer points.
- Avoid tools creating extremes of temperatures. This can damage soft tissue, cause bone thermal necrosis and affect operator precision and efficiency.
- Vibrating machinery should be deployed with caution to avoid white hand syndrome or Reynauds phenomenon in chronic users.
- Wear gloves that fit. Tight-fitting gloves can put pressure on the hands. Loose-fitting gloves reduce grip strength. Gloves reduce friction, making it harder to hold the device. They reduce the sensory input so that the power exerted by the operator on the tissue is difficult to judge.
References
- Patterson, Pat. OR exposure to electrosurgery smoke a concern. OR Manager 9 (June 1994)” 1, 6-7
- Roberts S, Ashcroft G, Murphy L. Assessment of Risk to Orthopaedic Surgeons from Hand Transmitted Vibration, Scottish Executive Health Department Chief Scientist Office.
- Hamish Love. “Noise exposure in the orthopaedic operating theatre: a significant health hazard” ANZ Journal of Surgery, Volume 73 Issue 10 Page 836, October 2003
- Armstrong TJ, Fine LJ, Goldstein SA, Lifshitz YR, Silverstein BA: Ergonomic considerations in hand and wrist tendinitis. J Hand Surg 12A, 830-837, 1987.
- Chaffin, D. B. Andersson, G. B. J. (1991) Occupational Biomechancis, New York: John Wiley & Sons.
- Johnson, S. L. (1990) Ergonomic Design of Handheld Tools to Prevent Trauma to the Hand and Upper Extremity, Journal of Hand Therapy, Vol 3, No 2, 86-93.
- Kinoshita H, Muras T, Bandou T, Grip posture and forces holding cylindrical objects with circular grips. Ergonomics, 39 (9), 1163-1176, 1996.
- Martin, BJ, Seminar: Hand Tools: Ergonomic Issues in Evaluation and Selection, conference hand-outs, sponsored by the University of Michigan Center for Occupational Health and Safety Engineering, Ann Arbor, Michigan, July, 1995
- Michael W. Kiser, President, Chapman Lake Instrument Corp. “Optimizing the Performance of Calcar and Patella Cutting Tools”. BONEZone • Summer 2003
- Putz-Anderson, V., (1988) Cumulative Trauma Disorder: A Manual for the Musculoskeletal Diseases of the Upper Limbs, New York: Taylor and Francis.
- Radwin RG, Haney JT, An Ergonomics Guide to Hand Tools, Virginia: American Industrial Health Association, 1996.
- Sanders MS, McCormick EJ, Human Factors in Engineering and Design, New York: McGraw-Hill, 1993.
- Tichauer, E.R. (1978) The Biomechanical Basis of Ergonomics, New York: John Wiley and Sons.
- Brandon J. Luskin, Susan Spinasanta. How to Choose and Use Hand and Power Tools to Reduce Risk of Injury. SpineUniverse. www.spineuniverse.com
- Mital A, Kilbom, A, Design selection and use of hand tools to alleviate trauma of the upper extremities: Part II - The scientific basis (knowledge base) for the guide. 10, September, 1992.
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