Incorporation of Phase Change Materials into the Surface of Aluminum Structures for Thermal Management.

This article explores the concept of generating a porous anodic layer on the surface of a metallic component to host a phase change material (PCM) aiming to reduce the peak temperatures that the host structure will experience. The conditions to fabricate a porous anodic layer on top of an aluminum substrate were determined through varying anodization conditions: solution concentration, voltage employed, and anodization times. Pore sizes were characterized using scanning electron microscopy. The alkane n-eicosane was selected as PCM, introduced within the porous anodic annealed layer using vacuum impregnation and the thin film composite structure sealed. Epoxy resin and a metallic paste were tested as sealants. Thermal tests were performed to compare the behavior of aluminum alloy substrates anodized and sealed with and without PCM. The results showed pores with diameters in the 5-85 nm range, with average values that increased as the time of anodization was extended. The aluminum alloy impregnated with n-eicosane presents lowered surface peak temperatures during heating cycles than the samples that were only anodized or than the base alloy, demonstrating the potential of PCM incorporated in the superficial microstructure of anodic structures to manage, to a certain extent, peak transient thermal loads.

Suture Anchor-Enhanced Medial Capsulorrhaphy of the Great Toe.

The suture anchor-enhanced medial capsulorrhaphy of the great toe is utilized as an adjuvant procedure to proximal and distal osteotomies for the treatment of hallux valgus. In traditional open techniques, hallux valgus repair requires both osseous correction along with shortening of the capsule on the medial side of the metatarsophalangeal joint. Osseous correction typically corrects the intermetatarsal angle, whereas capsular correction maintains the hallux valgus angle1. Description: A standard medial approach to the 1st metatarsophalangeal joint is performed. A medial midline horizontal capsulotomy is performed starting just proximal to the medial eminence and extending distally to the base of the proximal phalanx. Once the concomitant osseous and soft-tissue procedures are completed, a vertical capsulotomy is made in the inferior capsular flap at the level of the metatarsophalangeal joint in a manner perpendicular to the first ray in order to form an L shape. A 3 to 4-mm wedge of capsule is formed near the base of the vertical limb, running obliquely to the horizontal limb, and is excised. Optionally, the free limbs of the inferior capsule are imbricated. A unicortical hole is then drilled in the first metatarsal head, and a 2.7-mm outer diameter by 7-mm deep suture anchor with 2-0 FiberWire (Arthrex) is placed. The free ends of the suture are then utilized to close the horizontal capsulotomy in a running-locking interrupted fashion. Fluoroscopic imaging is performed throughout the procedure to prevent overcorrection and varus malignment. Alternatives: Alternative treatments include L-shaped capsulorrhaphy without suture anchor augmentation, dorsolinear capsulorrhaphy, Y-shaped capsulorrhaphy, and proximal hallux osteotomy or distal hallux osteotomy without capsulorrhaphy. Rationale: Anchor-enhanced capsulorrhaphy has been proven to assist in early maintenance of hallux valgus angle correction when combined with relevant distal osteotomy techniques. The anchor-enhanced capsulorrhaphy has an advantage over traditional capsulorrhaphy methods because it allows enhanced tightening of the capsule to the bone and, therefore, the potential for enhanced short-term maintenance. Additionally, the use of a running-locking interrupted suture technique reduces the number of suture knots required for capsular closure, potentially reducing the chance of complications such as suture granuloma formation. This technique is useful in all patients with hallux valgus deformity because it helps to provide durable deformity correction through additional modification of the soft tissues surrounding the 1st metatarsophalangeal joint. Expected Outcomes: Medial capsulorrhaphy has been shown to help with short-term reduction of the hallux valgus angle, both with and without the use of suture anchors1-3. Gould et al. demonstrated the superiority of adding suture anchors to the L-shaped medial capsulorrhaphy in order to aid in prevention of early postoperative relapse of the valgus deformity in patients undergoing chevron or modified McBride osteotomy1. We have utilized this suture anchor-enhanced capsulorrhaphy technique as an adjuvant procedure in most patients receiving osteotomies or Lapidus procedures for hallux valgus correction with consistent, reproducible results. In our experience, the suture anchor-enhanced medial capsulorrhaphy is an effective and time-efficient adjunctive soft-tissue corrective procedure in hallux valgus patients. Important Tips: Always excise a small capsular wedge to start with.Throughout the capsular tightening process, utilize clinical judgment and fluoroscopy to avoid pulling the hallux into varus malalignment.If varus is noted during plication of the plantar capsule, simply undo the tightening stitch.Because the majority of capsular tightening occurs at the first distal knot during the running horizontal capsular closure, if varus is noted, untie the knot and proceed with less correction.The extra cost of the suture anchor is a drawback but should be weighed against the enhanced durability of capsular correction compared with a traditional capsulorrhaphy.Always check the position of the suture anchor under fluoroscopy before proceeding with capsular closure in order to ensure proper deployment and adequate osseous purchase.Suture anchor failure can cause misleading radiographic presentation or joint impingement. Acronyms and Abbreviations: VAS = Visual analog scaleAOFAS = American Orthopaedic Foot & Ankle SocietyHV = Hallux valgusHVA = Hallux valgus angleMTP = Metatarsophalangeal jointDVT = Deep venous thrombosis.

Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk.

Importance: Surgical site infections (SSIs) are associated with increased morbidity and mortality. Various measures have been enacted decrease the occurrence of SSIs involving the regulation of the attire worn by the operating room staff, at times without sufficient peer-reviewed literature to support their implementation. Objective: To evaluate whether the combination of mandated surgical jackets and bouffants in the operating room is associated with the risk of surgical site infection. Design, Setting, and Participants: A retrospective cohort study of 34 042 inpatient surgical encounters at a large academic tertiary care hospital was performed. Three periods between January 2017 and October 2018 were compared, corresponding with implementation of surgical jackets and the subsequent mandate of surgical jackets plus bouffant head covers. All inpatient surgical cases were included from University of Alabama at Birmingham University Hospital, a single-center, large academic tertiary care hospital. The study comprised a consecutive sample of all inpatient surgical cases over a 22-month period. Exposures: No surgical jackets or bouffants mandated (8 months), surgical jackets mandated (6 months), both surgical jackets and bouffants mandated (8 months). Main Outcomes and Measures: The primary study outcome was SSIs, which were collected from institutional infection control monthly summary reports, according to the National Healthcare Safety Network definitions for superficial incisional, deep incisional, and organ/space SSIs. Secondary outcomes included wound dehiscence, postoperative sepsis, death, and cost of interventions. Results: A total of 34 042 inpatient surgical encounters cases were included in the analysis over the 22-month study period. Of the total patients, 16 380 were women (48%) and 17 638 were men (52%). There was no significant difference in the risk of SSI (1.01% vs 0.99% vs 0.83%; P = .28), mortality (1.83% vs 2.05% vs 1.92%; P = .54), postoperative sepsis (6.60% vs 6.24% vs 6.54%; P = .54), or wound dehiscence (1.07% vs 0.84% vs 1.06%; P = .20) between the 3 groups. Receipts from the first 6 months of the 2018/2019 fiscal year provided an estimated expenditure of more than $300 000 annually on surgical jackets. Bouffants were found to be less expensive than surgical skull caps. Conclusions and Relevance: The results of this study suggest that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSIs. Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.

Extensive Synovial Chondromatosis Involving All Flexor Tendons in the Tarsal Tunnel: A Case Report.

Synovial chondromatosis is a rare condition characterized by benign chondrogenic meta- plasia of extra-articular synovial tissue. It usually affects a single tendon sheath of the hand or foot. This report describes a rare case with extensive synovial chondromatosis affecting all flexor tendons in the tarsal tunnel, its radiological features, surgical treatment, and clinical outcome. The authors present a unique case of extensive synovial chondromatosis in a 48-year-old male involving the tendon sheaths of the flexor hallucis longus, flexor digitorum longus, and posterior tibialis tendons, at the level of the tarsal tunnel, with extension into the plantar aspect of the foot. The patient initially presented with symptoms of tarsal tunnel compression and was found to have a 4-cm mass in the posteromedial aspect of the ankle. The presumptive diagnosis of synovial chondromatosis was made based on radiographic and magnetic resonance imaging evidence. The patient underwent surgical resection of the tumor, as well as tarsal tunnel release and gastrocnemius recession. The diagnosis was confirmed postoperatively by surgical histopathology. The postoperative course of the patient was uncomplicated and his tarsal tunnel symptoms resolved. This represents a case of extensive synovial chondromatosis involving all flexor tendons in the tarsal tunnel that was correctly diagnosed by clinical and imaging findings, which required early surgical resection to avoid long-term neurovascular complications.

Extensive Synovial Chondromatosis Involving All Flexor Tendons in the Tarsal Tunnel: A Case Report / Condromatose sinovial extensa envolvendo todos os tendões do túnel do tarso: relato de caso

Abstract Synovial chondromatosis is a rare condition characterized by benign chondrogenic metaplasia of extra-articular synovial tissue. It usually affects a single tendon sheath of the hand or foot. This report describes a rare case with extensive synovial chondromatosis affecting all flexor tendons in the tarsal tunnel, its radiological features, surgical treatment, and clinical outcome. The authors present a unique case of extensive synovial chondromatosis in a 48-year-old male involving the tendon sheaths of the flexor hallucis longus, flexor digitorum longus, and posterior tibialis tendons, at the level of the tarsal tunnel, with extension into the plantar aspect of the foot. The patient initially presentedwith symptoms of tarsal tunnel compression and was found to have a 4-cm mass in the posteromedial aspect of the ankle. The presumptive diagnosis of synovial chondromatosiswasmadebased on radiographic and magnetic resonance imaging evidence. The patient underwent surgical resection of the tumor, aswell as tarsal tunnel releaseandgastrocnemius recession. The diagnosiswas confirmed postoperatively by surgical histopathology. The postoperative course of the patient was uncomplicated and his tarsal tunnel symptoms resolved. This represents a case of extensive synovial chondromatosis involving all flexor tendons in the tarsal tunnel that was correctly diagnosed by clinical and imaging findings, which required early surgical resection to avoid long-term neurovascular complications.

Resumo A condromatose sinovial é uma condição rara caracterizada por metaplasia condrogênica benigna do tecido sinovial extra-articular, que geralmente afeta uma única bainha tendínea da mão ou do pé. O objetivo é relatar o caso raro de um paciente com diagnóstico de condromatose sinovial extensa afetando todos os tendões flexores na topografia do túnel do tarso, suas características radiológicas, tratamento cirúrgico e desfecho clínico. Os autores apresentam um caso único de condromatose sinovial extensa em um homem de 48 anos envolvendo as bainhas dos tendões flexor longo do hálux, flexor longo dos dedos e tibial posterior, na topografia do túnel do tarso, com extensão para a região plantar do retropé. O sintoma inicial foi de compressão neurovascular (síndrome do túnel do tarso). A suspeita diagnóstica foi condromatose sinovial com base em evidências radiográficas e de ressonância magnética. O paciente foi submetido a ressecção cirúrgica do tumor, bem como a liberação do túnel tarsal e alongamento do tendão dos gastrocnêmios. O diagnóstico foi confirmado por exame histopatológico do espécime colhido no período intraoperatório. A evolução pósoperatória do paciente ocorreu sem complicações e os sintomas da síndrome do túnel do tarso cessaram. Os autores relatam um caso de condromatose sinovial extensa envolvendo todos os tendões flexores do túnel do tarso, corretamente diagnosticado por achados clínicos e radiológicos e que necessitou de ressecção cirúrgica precoce para evitar complicações neurovasculares em longo prazo.

Marijuana use and mortality following orthopedic surgical procedures.

Background: The association between marijuana use and surgical procedures is a matter of increasing societal relevance that has not been well studied in the literature. The primary aim of this study is to evaluate the relationship between marijuana use and in-hospital mortality, as well as to assess associated comorbidities in patients undergoing commonly billed orthopedic surgeries. Methods: The National Inpatient Sample (NIS) database from 2010 to 2014 was used to determine the odds ratios for the associations between marijuana use and in-hospital mortality, heart failure (HF), stroke, and cardiac disease (CD) in patients undergoing 5 common orthopedic procedures: total hip (THA), total knee (TKA), and total shoulder (TSA) arthroplasties, spinal fusion, and traumatic femur fracture fixation. Results: Of 9,561,963 patients who underwent one of the 5 selected procedures in the 4-year period, 26,416 (0.28%) were identified with a diagnosis of marijuana use disorder. In hip and knee arthroplasty patients, marijuana use was associated with decreased odds of mortality compared with no marijuana use (P < .0001) and increased odds of HF (P = .018), stroke (P = .0068), and CD (P = .0123). Traumatic femur fixation patients had the highest prevalence of marijuana use (0.70%), which was associated with decreased odds of mortality (P = .0483), HF (P = .0076), and CD (P = .0003). For spinal fusions, marijuana use was associated with increased odds of stroke (P < .0001) and CD (P < .0001). Marijuana use in patients undergoing total shoulder arthroplasty was associated with decreased odds of mortality (P < .001) and stroke (P < .001). Conclusions: In this study, marijuana use was associated with decreased mortality in patients undergoing THA, TKA, TSA, and traumatic femur fixation, although the significance of these findings remains unclear. More research is needed to provide insight into these associations in a growing surgical population.

Comparative Analysis of Short-Term Postoperative Complications in Outpatient Versus Inpatient Total Ankle Arthroplasty: A Database Study.

Ankle arthritis is a potentially debilitating disease, with approximately 50,000 cases diagnosed annually. One treatment option for these patients is total ankle arthroplasty (TAA). This procedure has historically been performed in the inpatient setting with a 1-2-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore it is important to evaluate the safety of specific procedures in the outpatient setting compared with the inpatient setting. This study evaluated the complication rates in inpatient versus outpatient TAA. It analyzed data from the National Surgical Quality Improvement Program for 591 patients who received TAA. Postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. Unadjusted direct comparisons of the cohorts revealed higher complication rates in the inpatient cohort. Inpatients had higher rates of superficial surgical site infections, deep surgical site infections, number of organ/space surgical site infections, pneumonia occurrences, and return to the operating room, but these differences were not significant. These results showed no significant increase in complication rates in outpatients compared to inpatients. Our results suggest that inpatient and outpatient TAA show similar complication rates. This suggests that outpatient TAA is safe and may be a superior option for certain populations. Further investigation is warranted to verify these conclusions.

Trends in surgical treatment of femoral neck fractures in the elderly.

OBJECTIVE: To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years). RESULTS: The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments. CONCLUSION: Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.

The Significance of Upper Extremity Neuromonitoring Changes During Thoracolumbar Spine Surgery.

STUDY DESIGN: This is a retrospective matched-pair cohort study. OBJECTIVE: To investigate the significance of upper extremity (UE) neuromonitoring changes in patients undergoing thoracolumbar surgery in prone position. SUMMARY OF BACKGROUND DATA: Peripheral nerve injuries in the UEs due to the prone positioning during prolonged thoracolumbar spinal procedures can cause diminished postsurgical outcomes. Intraoperative neuromonitoring has been utilized to alert the surgeon of the development of such injuries. MATERIALS AND METHODS: Patients who developed intraoperative ulnar somatosensory-evoked potential (SSEP) signal changes during posterior thoracolumbar surgery were identified and compared with a group of patients who did not develop such signal changes. The patients in 2 groups were pair-matched on the number of vertebral levels undergoing surgery. Data regarding intraoperative attempts to resolve signal changes and outcomes were collected. RESULTS: In total, 843 patients underwent thoracic, lumbar, or thoracolumbar spine surgeries in the prone position with intraoperative ulnar SSEPs neuromonitoring data available. Of these, 37 patients (4.4%) had intraoperative signal changes in the UEs. An equal number of patients without signal changes were also selected. In each group, 6 patients underwent thoracic, 20 patients underwent lumbar, and 11 patients underwent thoracolumbar procedures. In 8 patients (21.6%), there was no resolution of SSEP signal changes despite intraoperative attempts. The 2 groups were similar with respect to age and comorbidities. There was no significant difference in the mean body mass index (P=0.22). The mean duration of the procedures was 324 minutes in the SSEP signal change patients and 260 minutes in the patients without SSEP signal changes (P=0.03). No patient with UE SSEP changes had a clinically detectable neurological deficit postoperatively. CONCLUSIONS: UE SSEP signal changes during multilevel posterior thoracolumbar procedures are more likely to occur as the duration of the operation increases. The presence of UE signal changes does not coincide with clinically significant peripheral neuropathies. LEVEL OF EVIDENCE: Level III.

Nanotechnology in orthopedics: a clinically oriented review.

The utility of nanotechnology in medicine, specifically within the field of orthopedics, is a topic of extensive research. Our review provides a unique comprehensive overview of the current and potential future uses of nanotechnology with respect to orthopedic sub-specialties. Nanotechnology offers an immense assortment of novel applications, most notably the use of nanomaterials as scaffolds to induce a more favorable interaction between orthopedic implants and native bone. Nanotechnology has the capability to revolutionize the diagnostics and treatment of orthopedic surgery, however the long-term health effects of nanomaterials are poorly understood and extensive research is needed regarding clinical safety.

Trends in surgical treatment of femoral neck fractures in the elderly / Tendências no tratamento cirúrgico das fraturas do colo do fêmur em idosos

ABSTRACT Objective To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients. Methods The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years). Results The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments. Conclusion Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.

RESUMO Objetivo Analisar tendências recentes demográficas e de faturamento médico no tratamento de fraturas do colo do fêmur em idosos americanos. Métodos O banco de dados National Surgical Quality Improvement Program, do American College of Surgeons, foi analisado de 2006 a 2015, para pacientes com idade igual ou superior a 65 anos, usando os códigos de Current Procedural Terminology 27130, 27125, 27235 e 27236. Dados demográficos dos pacientes, complicações pós-operatórias e frequência de códigos foram comparados e analisados ao longo do tempo. A amostra teve 17.122 pacientes geriátricos, sendo 70% do sexo feminino, com média de idade de 80,1 anos (desvio padrão±6,6 anos). Resultados O número de casos aumentou no período, mas idade, gênero, índice de massa corporal e taxas de diabetes e tabagismo não mudaram ao longo do tempo. A fixação interna de redução aberta foi o código faturado mais comum, com 9.169 pacientes (53,6%), seguido por artroplastia parcial do quadril, com 5.861 (34,2%) pacientes. A probabilidade estimada combinada de morbidade foi de 9,8% (desvio padrão±5,2%) e não mudou significativamente ao longo do tempo. As taxas de complicações pós-operatórias foram semelhantes entre os tratamentos. Conclusão Os dados demográficos e as taxas de morbidade relacionadas às fraturas geriátricas do colo do fêmur não apresentaram mudança significativa entre 2006 e 2015. A redução aberta e a fixação interna foram as opções de tratamento mais comuns, seguidas da artroplastia parcial do quadril.

Workings of the human spirit in palliative care situations: a consensus model from the Chaplaincy Research Consortium.

BACKGROUND: Chaplaincy is a relatively new discipline in medicine that provides for care of the human spirit in healthcare contexts for people of all worldviews. Studies indicate wide appreciation for its importance, yet empirical research is limited. Our purpose is to create a model of human spiritual processes and needs in palliative care situations so that researchers can locate their hypotheses in a common model which will evolve with relevant findings. METHODS: The Model Building Subgroup worked with the Chaplaincy Research Consortium as part of a larger Templeton Foundation funded project to enhance research in the area. It met with members for an hour on three successive occasions over three years and exchanged drafts for open comment between meetings. All members of the Subgroup agreed on the final draft. RESULTS: The model uses modestly adapted existing definitions and models. It describes the human experience of spirituality during serious illness in three renditions: visual, mathematical, and verbal so that researchers can use whichever is applicable. The visual rendition has four domains: spiritual, psychological, physical and social with process arrows and permeable boundaries between all areas. The mathematical rendition has the same four factors and is rendered as an integral equation, corresponding to an integrative function postulated for the human spirit. In both renditions, the model is notable in its allowance for direct spiritual experience and a domain or factor in its own right, not only experience that is created through the others. The model does not describe anything beyond the human experience. The verbal rendition builds on existing work to describe the processes of the human spirit, relating it to the four domains or factors. CONCLUSIONS: A consensus model of the human spirit to generate hypotheses and evolve based on data has been delineated. Implications of the model for how the human spirit functions and how the chaplain can care for the patient or family caregiver's spiritual coping and well-being are discussed. The next step is to generate researchable hypotheses, results of research from which will give insight into the human spirit and guidance to chaplains caring for it.

Toward the development of peptide nanofilaments and nanoropes as smart materials.

Protein design studies using coiled coils have illustrated the potential of engineering simple peptides to self-associate into polymers and networks. Although basic aspects of self-assembly in protein systems have been demonstrated, it remains a major challenge to create materials whose large-scale structures are well determined from design of local protein-protein interactions. Here, we show the design and characterization of a helical peptide, which uses phased hydrophobic interactions to drive assembly into nanofilaments and fibrils ("nanoropes"). Using the hydrophobic effect to drive self-assembly circumvents problems of uncontrolled self-assembly seen in previous approaches that used electrostatics as a mode for self-assembly. The nanostructures designed here are characterized by biophysical methods including analytical ultracentrifugation, dynamic light scattering, and circular dichroism to measure their solution properties, and atomic force microscopy to study their behavior on surfaces. Additionally, the assembly of such structures can be predictably regulated by using various environmental factors, such as pH, salt, other molecular crowding reagents, and specifically designed "capping" peptides. This ability to regulate self-assembly is a critical feature in creating smart peptide biomaterials.