The Incidence of Perioperative Hypotension in Patients Undergoing Major Abdominal Surgery with the Use of Arterial Waveform Analysis and the Hypotension Prediction Index Hemodynamic Monitoring-A Retrospective Analysis.

Intraoperative hypotension (IH) is common in patients receiving general anesthesia and can lead to serious complications such as kidney failure, myocardial injury and increased mortality. The Hypotension Prediction Index (HPI) algorithm is a machine learning system that analyzes the arterial pressure waveform and alerts the clinician of an impending hypotension event. The purpose of the study was to compare the frequency of perioperative hypotension in patients undergoing major abdominal surgery with different types of hemodynamic monitoring. The study included 61 patients who were monitored with the arterial pressure-based cardiac output (APCO) technology (FloTrac group) and 62 patients with the Hypotension Prediction Index algorithm (HPI group). Our primary outcome was the time-weighted average (TWA) of hypotension below < 65 mmHg. The median TWA of hypotension in the FloTrac group was 0.31 mmHg versus 0.09 mmHg in the HPI group (p = 0.000009). In the FloTrac group, the average time of hypotension was 27.9 min vs. 8.1 min in the HPI group (p = 0.000023). By applying the HPI algorithm in addition to an arterial waveform analysis alone, we were able to significantly decrease the frequency and duration of perioperative hypotension events in patients who underwent major abdominal surgery.

Effect of screw angulation and multiple insertions on load-to-failure of polyaxial locking system.

PURPOSE: Polyaxial locking plates rely on the alignment between the thread-to-thread connections of the screw head and the plate hole. These implants have provided substantial support for surgeons. In particular, extended screw positioning have proven to be beneficial in the fixation of challenging fractures. This study aimed to investigate the mechanical properties of ChM 5.0 ChLP polyaxial screws inserted in off-axis trajectories, including multiple insertions and to correlate these parameters with the screw head and the plate hole thread-to-thread engagement. METHODS: Polyaxial locking screws were inserted into the plates at various angles (0°,10°,15°, -15° off-axis). Multiple time inserted screws were placed firstly at 15°, then 0° and finally -15° off-axis in the same plate hole. A microCT scan of the plate-hole and screw-head interface was conducted before destructive tests. Representative screws from each group were also examined by Scanning Electron Microscope. RESULTS: The standard insertion at 0° sustained the greatest maximum bending strength without relocation in the screw hole. Screws inserted at 10° and 15° (one time) showed a significant reduction in load-to-failure of up to 36% and 55%, (p = 0.001) (p = 0.001) respectively. Screws inserted at -15° after a maximum of three multiple insertions with angle shift, showed a total reduction in force of up to 70% (p = 0.001). A microCT analysis of thread engagement showed significant correlations. However, the results obtained for multiple insertions were highly variable. CONCLUSIONS: ChM 5.0 ChLP polyaxial locking system has valuable properties that foster fracture fixation, providing various surgical options. Nevertheless, the freedom of off-axis placement and multiple insertions of the screws comes at the price of reduced force. When possible surgeons should minimize the angles of insertions.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects.

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Effect of screw angulation on the bending performance of polyaxial locking interfaces: a micro-CT evaluation.

Polyaxial locking plates rely on a specific thread-to-thread interface of the screw head and the plate hole. The objective of this study was to evaluate the mechanical performance of single screw interfaces when inserted off-axis and to establish correlations between those parameters and the engagement of the screw head and the plate hole thread. Three polyaxial locking screw systems were inserted into the corresponding plates at various angles (0°, 5°, 10°, and 15° off-axis). The screws were tested until failure. A micro-CT was performed to examine the interface between the plate hole and the screw head. The standard insertion at 0° sustained the greatest maximum bending strength without relocation in the screw hole. Screws inserted at 15° showed a significant reduction in force of up to 44%, 55% and 57%, respectively. Micro-CT analysis of the interface showed a significant loss of thread engagement for off-axis insertion. Polyaxial plates offer additional advantages for off-axis placement of screws. However, this flexibility is related to a significant decrease in both thread engagement and bending strength compared to monoaxial insertion. Regardless the insertion angle, the loss of stability is comparable when screws are placed off-axis. Surgeons are advised to consider off-axis insertion as a salvage option, providing access to better bone stock.

Biomechanical evaluation of variable angle locking systems. A micro-CT analysis.

PURPOSE: Formerly poor bone stock and periprosthetic fractures used to jeopardize monaxial constructs. Polyaxial locking screws have substantially supported those particular fixation constructs. However, those systems rely on complex alignment between the screw head and the plate hole. This study aimed to investigate the mechanical properties of several polyaxial systems and to correlate these parameters with the screw head and the plate hole engagement. METHODS: Polyaxial locking systems were tested with screws inserted into the corresponding plates at various angles (0°, 5°, 10°, 15°). A micro-CT scan of the plate-hole and screw-head interface with the quantification of average thread engagement was performed before destructive tests. The screw-plate interface of each system was tested in a cantilever bending setup. Representative screws and plates were also examined by SEM. RESULTS: The standard insertion at 0° sustained the greatest maximum bending strength in all analyzed systems. Point-loading thread-in and cut-in screws inserted off-axis showed a significant reduction in bending strength (p<0.001) (p=0.041) (p<0.001). In contrast, locking cap screws maintained similar bending strength with disregard to the angle of insertion (p<0.4849). A micro-CT analysis confirmed that the average thread engagement of point-loading thread-in, cut-in and locking-cap screws was significantly reduced when placed off-axis (p=0.005) (p<0.001) (p=0.002) (p<0.001). The locking-cap mechanisms maintained the highest average thread engagement among all analyzed systems. CONCLUSIONS: The mechanical performance of polyaxial locking plates usually comes at the price of reduced bending strength. Surgeons should limit polyaxial insertions depending on the particular system's characteristics.

Quantification of Thread Engagement in Screw-Plate Interface of Polyaxial Locking System Using X-ray Computed Tomography.

This study demonstrates a new method for quantifying thread engagement in mechanical connections and verifies its applicability using biomedical implants under push-out tests. The focus is on orthopedic plate implants employed for bone fracture fixation, which, by design, allow off-axis screw insertion to accommodate different contact conditions. Thread engagement is crucial in determining connection strength and stability. In medical practice, off-axis screw placement is usually necessary due to bone geometries and implant plate rigidity. To address this, the study proposes a quantification method using non-destructive testing with X-ray micro-computed tomography and automated image processing, although tuning the image processing parameters is vital for accurate and reliable results. This enables detailed 3D models of screw-plate interfaces for precise thread engagement measurement. The results show that thread engagement decreases with both, increased off-axis insertion angles and higher torque during insertion. Correlation analysis reveals a strong relationship (R2 > 0.6) between average thread engagement and push-out strength, underscoring the importance of proper screw placement for stable fixation.

Do locking plugs improve implant strength? Biomechanical comparison of polyaxial locking constructs with and without locking plugs in a fracture gap model.

BACKGROUND: The objective of this study was to investigate the effects of locking plugs and the biomechanical properties of a 3.5 mm 8-hole polyaxial locking plate in a fracture gap model. Our hypothesis was that locking plugs would increase the strength and stiffness of the construct. Twelve 3.5 mm 8-hole plates were used to evaluate two different construct designs (with locking plugs vs. without locking plugs) with validated bone substitutes in a 25 mm bridging osteosynthesis gap model. Each construct was subjected to a single cycle four-point bending load to failure using a servo-hydraulic testing machine. Bending stiffness, bending strength, and bending structural stiffness were calculated and compared using an unpaired Student´s t-test. RESULTS: The plating construct with locking plugs did not show any significant increase in terms of bending stiffness, bending strength, and bending structural stiffness compared to plating construct without locking plugs in a 25 mm gap fracture model during a single cycle four-point bending. CONCLUSIONS: Under the conditions tested, filling empty plate holes with locking plugs in bridging osteosynthesis does not increase stiffness or strength of the plate-bone construct.

Intraoperative Hypotension Prediction-A Proactive Perioperative Hemodynamic Management-A Literature Review.

Intraoperative hypotension (IH) is a frequent phenomenon affecting a substantial number of patients undergoing general anesthesia. The occurrence of IH is related to significant perioperative complications, including kidney failure, myocardial injury, and even increased mortality. Despite advanced hemodynamic monitoring and protocols utilizing goal directed therapy, our management is still reactive; we intervene when the episode of hypotension has already occurred. This literature review evaluated the Hypotension Prediction Index (HPI), which is designed to predict and reduce the incidence of IH. The HPI algorithm is based on a machine learning algorithm that analyzes the arterial pressure waveform as an input and the occurrence of hypotension with MAP <65 mmHg for at least 1 min as an output. There are several studies, both retrospective and prospective, showing a significant reduction in IH episodes with the use of the HPI algorithm. However, the level of evidence on the use of HPI remains very low, and further studies are needed to show the benefits of this algorithm on perioperative outcomes.

What Is the Cost of Off-Axis Insertion of Locking Screws? A Biomechanical Comparison of a 3.5 mm Fixed-Angle and 3.5 mm Variable-Angle Stainless Steel Locking Plate Systems.

OBJECTIVE: The aim of this study was to evaluate the effect of screw insertion angle and insertion torque on the mechanical properties of a 3.5 fixed-angle locking plate locking compression plate (LCP) and 3.5 variable-angle locking plate polyaxial locking system (PLS). METHODS: In the LCP group, screws were placed abaxially at 0, 5 and 10 degrees. In the PLS group, screws were placed at 0, 5, 10, 15 and 20 degrees abaxially. The insertion torque was set to 1.5 and 2.5 Nm in the LCP and PLS groups respectively. A load was applied parallel to the screw axis, and the screw push-out force was measured until the locking mechanism was loosened. RESULTS: The 3.5 LCP showed higher push-out strength than the 3.5 PLS when the screws were placed at 0 degree regardless of the insertion torque. The off-axis insertion of 3.5 LCP locking screws resulted in a significant decrease in push-out strength (p < 0.05). A higher insertion torque value significantly increased the screw holding strength for the 3.5 LCP (p < 0.05). The 3.5 PLS system had a significantly higher push-out force when the screws are at 0 degree than at 5, 10 and 15 degrees, and 20 degrees (p < 0.05) at any given insertion torque. An increase in the insertion torque did not have a significant effect on the push-out strength of the 3.5 PLS locking system. CONCLUSION: The 3.5 PLS is more sensitive to the screw insertion angle than to the insertion torque, whereas the 3.5 LCP is affected by both factors. Placing 3.5 LCP locking screws off-axis significantly reduces the screw holding strength; therefore, this approach has to be avoided. The findings of our research indicate that a 1.5 Nm torque can be used for a 3.5 PLS.

Discrimination of Surface Topographies Created by Two-Stage Process by Means of Multiscale Analysis.

The fundamental issue in surface metrology is to provide methods that can allow the establishment of correlations between measured topographies and performance or processes, or that can discriminate confidently topographies that are processed or performed differently. This article presents a set of topographies from two-staged processed steel rings, measured with a 3D contact profilometer. Data were captured individually from four different regions, namely the top, bottom, inner, and outer surfaces. The rings were manufactured by drop forging and hot rolling. Final surface texture was achieved by mass finishing with spherical ceramic media or cut wire. In this study, we compared four different multiscale methods: sliding bandpass filtering, three geometric length- and area-scale analyses, and the multiscale curvature tensor approach. In the first method, ISO standard parameters were evaluated as a function of the central wavelength and bandwidth for measured textures. In the second and third method, complexity and relative length and area were utilized. In the last, multiscale curvature tensor statistics were calculated for a range of scales from the original sampling interval to its forty-five times multiplication. These characterization parameters were then utilized to determine how confident we can discriminate (through F-test) topographies between regions of the same specimen and between topographies resulting from processing with various technological parameters. Characterization methods that focus on the geometrical properties of topographic features allowed for discrimination at the finest scales only. Bandpass filtration and basic height parameters Sa and Sq proved to confidently discriminate against all factors at all three considered bandwidths.

Multiscale Analysis of Surface Texture Quality of Models Manufactured by Laser Powder-Bed Fusion Technology and Machining from 316L Steel.

The paper presents the results of tests aimed at evaluating the surface textures of samples manufactured from material based on 316L stainless steel. The analysis of the surface topography was conducted based on the classical approach in accordance with the current standard and with the use of multiscale methods; i.e., wavelet transformation and geometric via curvature. Selective laser melting 3D printing technology was used to produce samples for surface testing. Furthermore, additional assessment of surfaces created as result of milling was conducted. Statistical research demonstrated a differentiation in the distribution of particular morphological features in certain ranges of the analyzed scales.

Application of a simulation model to the prognosis of material loss in wood processing.

The article discusses the influence of a sample size on the credibility of a simulation model created for the estimation of material loss in the production of a middle layer of a wooden floorboard. The study was conducted in a production company operating in the wood processing industry. Geometric characteristics of input material were captured and used to derive statistical distributions, which were then included in the simulation model. The conducted experiments indicated that the quality of the simulation model was significantly affected by the quality and quantity of the sample, on the basis of which the stochastic model is estimated. It was shown that small sample for wood processing data was insufficient to capture process variability. On the other hand, excessive sample size (80 or more observations) for the material with high natural geometric variability, involves taking into account outliers, which may lower the overall prognostic quality of the simulation model. Based on the conducted simulation experiments, the recommended sample size which allows development of a reliable model for estimation of material loss in the analyzed manufacturing process, ranges from 40 to 60 measurements.

Analysis of Surface Microgeometry Created by Electric Discharge Machining.

The objective of this work is to study the geometric properties of surface topographies of hot-work tool steel created by electric discharge machining (EDM) using motif and multiscale analysis. The richness of these analyses is tested through calculating the strengths of the correlations between discharge energies and resulting surface characterization parameters, focusing on the most representative surface features-craters, and how they change with scale. Surfaces were created by EDM using estimated energies from 150 to 9468 µJ and measured by focus variation microscope. The measured topographies consist of overlapping microcraters, of which the geometry was characterized using three different analysis: conventional with ISO parameters, and motif and multiscale curvature tensor analysis. Motif analysis uses watershed segmentation which allows extraction and geometrically characterization of each crater. Curvature tensor analysis focuses on the characterization of principal curvatures and their function and their evolution with scale. Strong correlations (R2 > 0.9) were observed between craters height, diameter, area and curvature using linear and logarithmic regressions. Conventional areal parameter related to heights dispersion were found to correlate stronger using logarithmic regression. Geometric characterization of process-specific topographic formations is considered to be a natural and intuitive way of analyzing the complexity of studied surfaces. The presented approach allows extraction of information directly relating to the shape and size of topographic features of interest. In the tested conditions, the surface finish is mostly affected and potentially controlled by discharge energy at larger scales which is associated with sizes of fabricated craters.

Multiscale Characterizations of Surface Anisotropies.

Anisotropy can influence surface function and can be an indication of processing. These influences and indications include friction, wetting, and microwear. This article studies two methods for multiscale quantification and visualization of anisotropy. One uses multiscale curvature tensor analysis and shows anisotropy in horizontal coordinates i.e., topocentric. The other uses multiple bandpass filters (also known as sliding bandpass filters) applied prior to calculating anisotropy parameters, texture aspect ratios (Str) and texture directions (Std), showing anisotropy in horizontal directions only. Topographies were studied on two milled steel surfaces, one convex with an evident large scale, cylindrical form anisotropy, the other nominally flat with smaller scale anisotropies; a µEDMed surface, an example of an isotropic surface; and an additively manufactured surface with pillar-like features. Curvature tensors contain the two principal curvatures, i.e., maximum and minimum curvatures, which are orthogonal, and their directions, at each location. Principal directions are plotted for each calculated location on each surface, at each scale considered. Histograms in horizontal coordinates show altitude and azimuth angles of principal curvatures, elucidating dominant texture directions at each scale. Str and Std do not show vertical components, i.e., altitudes, of anisotropy. Changes of anisotropy with scale categorically failed to be detected by traditional characterization methods used conventionally. These multiscale methods show clearly in several representations that anisotropy changes with scale on actual surface measurements with markedly different anisotropies.

How Do the Locking Screws Lock? A Micro-CT Study of 3.5-mm Locking Screw Mechanism.

OBJECTIVE: To quantify the amount of the screw head thread and the plate hole thread connection in two 3.5 mm locking plates: Locking Compression Plate (LCP) and Polyaxial Locking System (PLS). MATERIALS AND METHODS: A micro - CT scan of a screw head - plate hole connection was performed pre- and post destructive tests. Tests were performed on bone surrogates in a fracture gap model. The 3.5 LCP and 3.5 PLS plates, with 3 perpendicular screws per segment were used in a destructive static test. The 3.5 PLS plates with mono- and polyaxial screws were compared in a cyclic fatigue tests in two orthogonal directions. Pre - and post - test scan datasets were compared. Each dataset was converted into serial images depicting sections cut orthogonally to locking screw axis. The amount of engagement was detected through automated image postprocessing. RESULTS: The mean amount of the thread connection for the LCP was 28.85% before and 18.55% after destructive static test. The mean amount of the connection for the PLS was 16.20% before and 14.55% after destructive static test. When inserted monoaxially, the mean amount of the connection for the PLS screws was 14.4% before and 19.24% after destructive cyclic test. The mean amount of the connection for the polyaxial inserted PLS screws when loaded against plate thickness was 2.99% before and 2.08% after destructive cyclic test. The mean amount of the connection for the polyaxial inserted PLS screws when loaded against plate width was 3.36% before and 3.93% after destructive cyclic test. The 3D visualization of the thread connection showed that the initial interface points between screw head and plate hole are different for both LCP and PLS after the destructive testing. Depending on the type of applied force, there was either loss or increase of the contact. CLINICAL RELEVANCE: Micro-CT offers news possibilities in locking implant investigation. It might be helpful in better understanding the nature of locking mechanism and prediction of possible mode of failure in different systems.

Mechanical Performance of a Polyaxial Locking Plate and the Influence of Screw Angulation in a Fracture Gap Model.

OBJECTIVE: The aim of this study was to compare the locking compression plate (LCP) with polyaxial locking system (PLS) using single cycle to failure 4-point bending test and to investigate the behaviour of PLS with screws inserted mono- and polyaxially using cyclic fatigue test in two bending directions. MATERIALS AND METHODS: Tests were performed on bone surrogates in a fracture gap model. The 3.5 LCP and 3.5 PLS plates were tested in single cycle to failure. The 3.5 PLS plates with mono- and polyaxial screws were compared in a cyclic fatigue tests in two orthogonal directions. For both experiments, micro-computed tomography (CT) scans were performed pre- and post-testing to investigate the connections between the screw head and the plate hole. Means of forces and cycles needed to failure were statistically compared. RESULTS: The PLS plates were on average 30% weaker than LCP plates. Mode of failure was plate bending in the single cycle to failure tests, and plate breakage in the cyclic fatigue tests. Neither screw breakage nor loss of the screw-plate interface occurred. Mono- and polyaxial constructs performed similarly when loaded in the same direction. Micro-CT revealed no additional internal cracks in the plates or screws after testing. It also showed for both PLS and LCP that there was only partial contact of the screw head with the plate hole. CLINICAL RELEVANCE: PLS offers a durable locking system, even when the screws are placed polyaxially. The weaker bending properties of the PLS compared with LCP should be considered during preoperative planning.

Multiscale 3D Curvature Analysis of Processed Surface Textures of Aluminum Alloy 6061 T6.

The objectives of this paper are to demonstrate the viability, and to validate, in part, a multiscale method for calculating curvature tensors on measured surface topographies with two different methods of specifying the scale. The curvature tensors are calculated as functions of scale, i.e., size, and position from a regular, orthogonal array of measured heights. Multiscale characterization of curvature is important because, like slope and area, it changes with the scale of observation, or calculation, on irregular surfaces. Curvatures can be indicative of the topographically dependent behavior of a surface and, in turn, curvatures are influenced by the processing and use of the surface. Curvatures of surface topographies have not been well- characterized yet. Curvature has been used for calculations in contact mechanics and for the evaluation of cutting edges. Manufactured surfaces are studied for further validation of the calculation method because they provide certain expectations for curvatures, which depend on scale and the degree of curvature. To study a range of curvatures on manufactured surfaces, square edges are machined and honed, then rounded progressively by mass finishing; additionally, a set of surfaces was made by turning with different feeds. Topographic measurements are made with a scanning laser confocal microscope. The calculations use vectors, normal to the measured surface, which are calculated first, then the eigenvalue problem is solved for the curvature tensor. Plots of principal curvatures as a function of position and scale are presented. Statistical analyses show expected interactions between curvature and these manufacturing processes.