AOA Critical Issues Symposium: Leadership and Education During and After COVID-19: Back to the Future or a New Normal.

ABSTRACT: The devastating impact of COVID-19 has reshaped how we lead and train our future surgeons in the field of orthopaedics. Overnight, leaders in our field had to dramatically shift their mindset to continue to lead a hospital, department, journal, or residency or fellowship program in the face of an unprecedented level of adversity in the history of the United States. This symposium discusses the role of physician leadership during and after a pandemic, as well as the adoption of technology for training surgeons in the field of orthopaedics.

Nanocrystalline diamond coatings for mechanical seals applications.

A mechanical seal is a type of seal used in rotating equipment, such as pumps and compressors. It consists of a mechanism that assists the connection of the rotating shaft to the housings of the equipments, preventing leakage or avoiding contamination. A common cause of failure of these devices is end face wear out, thus the use of a hard, smooth and wear resistant coating such as nanocrystalline diamond would be of great importance to improve their working performance and increase their lifetime. In this paper, different diamond coatings were deposited by the HFCVD process, using different deposition conditions. Additionally, the as-grown films were characterized for, quality, morphology and microstructure using scanning electron microscopy (SEM) and Raman spectroscopy. The topography and the roughness of the films were characterized by atomic force microscopy (AFM).

Tuning the conditions for the deposition of nanocrystalline diamond by hot filament chemical vapour deposition.

Although large focus has been placed into the deposition of nanocrystalline and ultra-nanocrystalline diamond films, most of this research uses microwave plasma assisted CVD systems. However, the growth conditions used in microwave systems cannot be directly used in hot-filament CVD systems. This paper, aims to enlarge the knowledge of the diamond film depositing process. H2/CH4/Ar gas mixtures have been used to deposit micro, nano and ultra-nanocrystalline diamond films by hot-filament CVD systems. Additionally, the distance between the filaments array and the substrate was varied, in order to observe its effect and consequently the effect of a lower substrate temperature in the nucleation density and deposition. All the samples were characterized for microstructure and quality, using scanning electron microscopy and Raman spectroscopy.

Comparative study of nanocrystalline diamond deposition on WC-Ni and WC-Co substrates.

Tungsten carbide alloys possess a large number of applications, due to its high hardness, high resistance to heat and to wear, which makes it ideal to be used in wear parts of machinery or on surfaces liable to corrosion, abrasion or high temperatures. For practical applications, it is alloyed with cobalt (Co) or nickel (Ni) in order to improve its properties. The increasing demand of broadening the operation limits of some components, impose the need to improve its life time. Coating these parts with hard and smooth diamond thin film may improve the wear performance and decrease their roughness and friction coefficient. In this work, a comparative study of nanodiamond films deposit onto WC-Co and WC-Ni, by means of a hot-filament Chemical Vapour Deposition (HFCVD) system, is presented. The study was accomplished by varying the CH4/H2/Ar gas ratio of the deposition process. The substrate temperature was kept low (< 700 degrees C) to minimize the thermal stress in the coating-substrate system. The microstructure of the deposited diamond film was characterized using Scanning Electron Microscopy (SEM), Raman spectroscopy and X-ray diffraction spectroscopy. Roughness of the working surfaces were also accessed prior and after the depositions.

Hybrid layers deposited by an atmospheric pressure plasma process for corrosion protection of galvanized steel.

Finding alternative treatments to reproduce anticorrosion properties of chromated coatings is challenging since both physical barrier and self-healing effects are needed. Siloxane based treatments are known to be a promising way to achieve physical barrier coatings, mainly plasma polymerized hexamethyldisiloxane (ppHMDSO). In addition, it is known that cerium-based coatings can also provide corrosion protection of metals by means of self-healing effect. In this frame, innovative nanoAlCeO3/ppHMDSO layers have thus been deposited and studied. These combinations allow to afford a good physical barrier effect and active properties. Liquid siloxane and cerium-based particles mixture is atomized and introduced as precursors into a carrier gas. Gas mixture is then injected into an atmospheric pressure dielectric barrier discharge (DBD) where plasma polymerization of the siloxane precursor occurs. The influence of cerium concentration on the coating properties is investigated: coating structure and topography have been studied by scanning electron microscopy (SEM) and interferometry, and corrosion resistance of these different coatings is compared by electrochemistry techniques: polarization curves and electrochemical impedance spectroscopy (EIS). Potential self-healing property afforded by cerium in the layer was studied by associating EIS measurements and nanoscratch controlled damaging. Among the different combinations investigated, mixing of plasma polymerized HMDSO and AICeO3 nanoparticles seems to give promising results with a good physical barrier and interesting electroactive properties. Indeed, corrosion currents measured on such coatings are almost as low as those measured with the chromated film. Combination of nanoscratch damaging of layers with EIS experiments to investigate self-healing also allow to measure the active protection property of such layers.

Investigation of the stiffness and yield behaviour of melt-intercalated poly(methyl methacrylate)/organoclay nanocomposites: characterisation and modelling.

The elastic modulus and yield stress behaviour of a melt intercalated Poly(methylmethacrylate)/ organoclay (PMMA/C30B and PMMA/C20A) were studied using uniaxial tensile tests at different temperatures and different strain rate. The stress-strain response was obtained for different loading rates and different test temperature. Both the stiffness and the yield stress were then clearly identified as function of strain rate and temperature. Our experimental results show that the yield stress and modulus of both PMMA/C20A and PMMA/C30B organoclay nanocomposites are very sensitive to clay concentration, strain rate and temperature. A micromechanically-based composite approach was used to predict the yield stress of both PMMA/C20A and PMMA/C30B organoclay nanocomposites. The results obtained from the model are in good agreement with our experimental results. As expected, the activation enthalpy of cooperative model increased slightly while the activation volume decreases slightly with the clay concentration.

Towards optimization of time modulated chemical vapour deposition for nanostructured diamond films on Ti6Al4V.

In this paper, we report the use of the TMCVD technique for the optimisation of deposited diamond films onto Ti6Al4V substrates. A number of samples were made varying the experimental parameters. The specimen surfaces were characterised using micro Raman spectra and SEM analyses. Results show that very different surface finish (from micro to nanostructures) and film characteristics can be obtained from the experimental parameters used. The quality of deposited diamond is very dependant on the experimental settings and process. It was found that lower residual stresses are developed using the TMCVD technique than with conventional CVD but depend on the structural diamond growth during the process. The quality of the deposited film was evaluated as a function of diamond to amorphous carbon ratio but showed no direct relation with the surface finish since it characterises the quality of the deposited diamond but not the quality of the film surface.

Use of functionalized nanosilica to improve thermo-mechanical properties of epoxy adhesive joint bonding aluminium substrates.

The present work is concerned with the improvement of thermal properties and mechanical strength of adhesive joints consisting of an epoxy adhesive layer bonding aluminium substrates by grafted nanosilica. Epoxy resin/silica nanocomposites were prepared by using functionalized silica. Silica was functionalized by amine group (SiO2-NH2). It was identified by Raman and Fourier Transform Infrared (FTIR). Effects of silica on viscoelastic properties for epoxy resin and its assemblies with aluminium substrates were studied by Dynamical Mechanical Analysis (DMA). Particles distribution was characterized by Scanning Electron Microscope (SEM). Our experimental results showed that functionalized silica presents a better distribution in the matrix than the pure silica. Our results also showed that grafting of functionalized silica improves the glass transition temperature (Tg) and the ultimate strength of aluminium/epoxy/aluminium assembly.

Game-based training in young elite handball players.

This study compared the effect of high-intensity interval training (HIT) versus specific game-based handball training (HBT) on handball performance parameters. Thirty-two highly-trained adolescents (15.5+/-0.9 y) were assigned to either HIT (n=17) or HBT (n=15) groups, that performed either HIT or HBT twice per week for 10 weeks. The HIT consisted of 12-24 x 15 s runs at 95% of the speed reached at the end of the 30-15 Intermittent Fitness Test (V(IFT)) interspersed with 15 s passive recovery, while the HBT consisted of small-sided handball games performed over a similar time period. Before and after training, performance was assessed with a counter movement jump (CMJ), 10 m sprint time (10 m), best (RSAbest) and mean (RSAmean) times on a repeated sprint ability (RSA) test, the V(IFT) and the intermittent endurance index (iEI). After training, RSAbest (-3.5+/-2.7%), RSAmean (-3.9+/-2.2%) and V(IFT) (+6.3+/-5.2%) were improved (P<0.05), but there was no difference between groups. In conclusion, both HIT and HBT were found to be effective training modes for adolescent handball players. However, HBT should be considered as the preferred training method due to its higher game-based specificity.

Outcomes of sympathectomy and vascular bypass for digital ischaemia in connective tissue disorders.

All patients (36 hands) with connective tissue disorders who underwent periarterial sympathectomy of the hand alone or in conjunction with vascular bypass at our institution between 1995-2013 were reviewed. The durable resolution of ulcers was significantly higher in patients treated by periarterial sympathectomy and bypass than in patients treated by periarterial sympathectomy alone. Although there were more digital amputations in patients treated by periarterial sympathectomy alone, the difference was not statistically significant. Vascular bypass in conjunction with sympathectomy may be better than sympathectomy alone in patients with digital ischaemia related to connective tissue disorders. LEVEL OF EVIDENCE: IV.

Secondary ion and laser ablation mass spectrometry for the quantitative characterization of styrene-butadiene copolymers.

Styrene-butadiene copolymers were analyzed by static secondary ion mass spectrometry (S-SIMS) and laser ablation Fourier transform ion cyclotron resonance mass spectrometry (LA-FTICRMS) to obtain quantitative information based on specific ions. Silver deposition was performed on polystyrene, butadiene rubber and styrene-butadiene rubber. Under these experimental conditions, new secondary ions were detected, in particular silver-cationized butadiene [M(butadiene) - Ag](+) and styrene [M(styrene) - Ag](+) monomers. In contrast, LA-FTICRMS experiments did not require pretreatment. At high laser power density, UV photons (193, 266 and 355 nm) allowed the detection of styrene and butadiene monomers at m/z 104 and 54, respectively. The use of the observed ions by SIMS or LA-FTICRMS ensures that quantitative information on the relative distribution of each monomer is obtained. However, the silver coating thickness in the SIMS experiment seems to have an important influence on the quantitative information obtained. For LA-FTICRMS experiments, the best results are obtained at a wavelength of 355 nm.

The fibula-flexor hallucis longus osteomuscular flap.

Limb salvage after loss of bone and soft tissue may require many operations to obtain soft-tissue cover and bony continuity. We describe a fibula-flexor hallucis longus osteomuscular flap which can provide both soft tissue and bone in a single stage. The flap is based on the peroneal vessels and is covered by a split-thickness skin graft. We report the results in five patients with an average bone defect of 8.3 cm and soft-tissue and skin loss. All regained a normal gait on the donor side; four had clinical and radiological union with excellent soft-tissue cover, but one required later amputation due to diffuse coagulopathy. The flap provides free vascularised bone with muscle cover. It has a dependable, long pedicle with minimal morbidity at the donor site, and allows monitoring of the vascularity of the fibular graft.

Complications associated with traction on the hip during arthroscopy.

We studied 16 hips (eight cadaver specimens) using arthrography, arthroscopy and anatomical dissection, under incremental traction of up to a maximum of 64 kg, to determine the relationship of the portals to nearby neurovascular structures. The distance of each arthroscopic portal (anterior, anterolateral, and posterolateral) to the associated neurovascular structures was measured after the application of 23 kg of traction. Traction of up to 64 kg on the lower limb failed to produce evidence of labral or capsular injury. Furthermore, traction of 23 kg resulted in little change in the position of adjacent neurovascular structures relative to the standard arthroscopic portals.

Management of vasospastic disorders of the hand.

Vasospastic disorders of the upper extremity are common and often difficult to treat. Using the proposed classification system (Table 2) allows management based upon pathologic condition, physiologic staging, and response to treatment. Identifying patients in this way also helps in determining which treatments are most appropriate. The basic approach to management includes environmental and behavioral modifications including cessation of tobacco use, protection of hands, and avoidance of situations that trigger the vasospastic response. Pharmacologic therapy may provide good results in a majority of patients. Surgical intervention is reserved for patients with vaso-occlusion, ischemia, and refractory symptoms in spite of attempts at medical management. Surgical options include vascular reconstruction, peripheral sympathectomy, or a combination of techniques. The goal of medical and surgical management is to increase total or nutritional blood flow in the digits.

Arthroscopic and open management of dynamic scaphoid instability.

This article focuses on the pathophysiology and treatment of dynamic scaphoid instability. Cadaver studies suggest that dynamic instability results from isolated injury to the scapholunate interosseous ligament without damage to the dorsal intercarpal and dorsal radial lunotriquetral ligaments. The diagnosis may be made by dynamic fluoroscopic examination, including stress and load views. The role of arthroscopy is twofold: (1) it enables the surgeon to distinguish between a complete, grossly unstable scapholunate interosseous space that requires open treatment and (2) it permits direct visualization of the reduction and percutaneous pinning of the articulation in an effort to stabilize the joint. Operative indications, open and arthroscopic techniques, and results are discussed.

Fixation of three-part proximal humeral fractures: a biomechanical evaluation.

OBJECTIVES: To examine the biomechanical stability of three constructs currently used for the management of three-part proximal humerus fractures. Tension band wires (TBW) with supplemental Enders nails, modified cloverleaf plate and screws, and intramedullary (IM) nailing with proximal and distal interlocks were tested to determine relative stability. DESIGN: A reproducible three-part fracture was made in fresh-frozen stripped proximal humeri. The fracture was stabilized using TBW/Enders nail (n = 6), plate/screws (n = 5), or IM nailing (n = 5). MAIN OUTCOME MEASUREMENTS: Mechanical testing was performed with a small preload followed by deflection of five millimeters at a rate of one millimeter per second in flexion, extension, and varus and valgus relative to the humeral shaft. A load-displacement curve was obtained. Torsional testing was performed in internal and external rotation, and torque-rotation curves were recorded. RESULTS: In cantilever bending, the plate/screws construct and the IM nail construct were superior to the TBW/Enders nail construct for all parameters except extension. There was no statistically significant difference between the IM nail and the plate/screws groups. Torsional stiffness testing revealed that the plate/screws and the IM nail were superior to the TBW/Enders nail construct. There was no statistical difference between the IM nail and the plate/screws groups. CONCLUSIONS: In a cadaveric model of three-part proximal humerus fractures stripped of soft tissue, plate/screws fixation and IM nailing provide greater torsional and bending stiffness than does fixation with TBW/Enders nail. There was no statistically significant difference in torsional or bending stiffness between IM nailing with interlocks and plate/screws fixation in this model.

Arthroscopic excision of the radial head: Clinical outcome in 12 patients with post-traumatic arthritis after fracture of the radial head or rheumatoid arthritis.

PURPOSE: We performed arthroscopic radial head excision in a series of patients with either post-traumatic arthritis after a radial head fracture or rheumatoid arthritis of the elbow as an expanded indication for elbow arthroscopy. The purpose of the study was to critically examine the results of arthroscopic chondroplasty of the radial head to determine the safety and effectiveness of the procedure. TYPE OF STUDY: Outcome study and retrospective analysis. METHODS: From 1990 to 1997, arthroscopic radial head resection was performed in 12 patients with either post-traumatic arthritis (n = 10, Mason type II or III) or with rheumatoid arthritis (n = 2). Functional outcome and radiographs were analyzed after a mean follow-up period of 39 months (range, 12 to 97 months). Elbow arthroscopy was performed using a standardized technique. The anterior three quarters of the radial head and 2 to 3 mm of the radial neck were resected with the abrader in the anterolateral portal and the arthroscope in the proximal medial portal. For resection of the posterior portion of the radial head, the abrader may be transferred to the mediolateral portal. This permits resection of the remnants of the radial head posteriorly and also at the proximal radioulnar joint. RESULTS: Preoperatively, patients lacked 23 degrees (range, 5 degrees to 40 degrees ) of extension of the elbow on average. Mean flexion was 111 degrees (range, 60 degrees to 145 degrees ). Patients had unrestricted pronation (limitation of 5 degrees in 2 patients). Two patients had a lack of supination of 15 degrees and 30 degrees. Mean follow up was 39 months (range, 12 to 97 months). Postoperatively, patients lacked 9 degrees (range, 0 degrees to 20 degrees ) of extension of the elbow on average. Mean flexion was 136 degrees (range, 90 degrees to 150 degrees ). No patient had subjective or objective evidence of instability of the elbow. All patients except one reported significant improvement in pain relief and complete relief of mechanical symptoms. CONCLUSIONS: This technically demanding surgical procedure should be reserved for situations of persistent, restricted range of motion and chronic pain. Arthroscopic radial head resection combined with arthroscopic synovectomy relieves elbow stiffness. The surgeon is able to deal with the intrinsic joint pathology, as well as with accompanying symptoms such as synovitis, capsular contracture, or loose bodies.

Arthroscopic treatment of Panner's disease.

Panner's disease, or osteochondrosis of the capitellum, may actually be a continuum of disorders. In the past, such lesions were treated conservatively with surgery as a final option. With the advent of arthroscopy, a diagnosis can be made, and treatment with limited invasiveness instituted. This article reviews the diagnostic and therapeutic advantages of arthroscopic techniques in the treatment of Panner's disease.

The landscape of meniscal injuries.

This article analyzes meniscal injuries seen in 10,117 knee arthroscopies. The information was compiled by a centralized data base at Surgical Data Management. The study suggests two patterns of meniscal injuries, degenerative and traumatic. Injuries to the menisci occurring with an associated anterior cruciate injury, radial tears, and tears within 3 mm of the meniscosynovial junction are associated with a younger and more active patient who is more likely to sustain a traumatic or sports-related injury. Tears described as complex, horizontal cleavage, and flap tears are associated with an older age group and follow a more degenerative pattern.

Endoscopic carpal tunnel release. The Agee technique.

The authors describe their technique for endoscopic carpal tunnel release using the Agree device. Technical points, illustrations, and postoperative regimen are provided.