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Thermal Tissue Damage Caused by Ultrasonic Cement Removal from the Humerus
Steven H. Goldberg, MD1; Mark S. Cohen, MD1; Michael Young, PHD, MSC2; Brian Bradnock, FRCS(ED), FRCS(ORTH)3
1 Department of Orthopaedic Surgery, Rush University Medical Center, 1653 W. Congress Parkway, 1471 Jelke, Chicago, IL 60612. E-mail address for S.H. Goldberg: steven_h_goldberg@rush.edu
2 Orthosonics Ltd, Bremridge House, Ashburton, S. Devon TQ13 7JX, United Kingdom
3 St. Albans and Hemel Hempstead NHS Trust, Waverly Road, St. Albans, Herts, United Kingdom
View Disclosures and Other Information
One of the authors (M.Y.) is a full-time salaried employee of Orthosonics Ltd. One of the authors (B.B.) is a part-time paid consultant to Orthosonics Ltd. The other two authors (S.H.G. and M.S.C.) did not receive any payments or benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. The equipment used in this study was provided by Orthosonics Ltd, Stryker Instruments, Howmedica, and Biomet. The cadavera were provided by Anatomical Service, Inc.
Investigation performed at the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Mar 01;87(3):583-591. doi: 10.2106/JBJS.D.01966
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Background: Ultrasound devices can selectively remove cement during revision arthroplasty. These instruments initially were designed for the hip and knee but also have been applied to the upper extremity. We describe a patient in whom a radial nerve palsy and a pathologic humeral fracture developed after ultrasonic cement removal was performed because of an infection at the site of a total elbow arthroplasty. Biopsies of the humerus, the triceps muscle, and the radial nerve showed widespread necrosis consistent with thermal injury.

Methods: A study involving six human cadaveric specimens was conducted to measure temperature elevations in bone and adjacent soft tissue during cement removal with use of an ultrasound device with and without irrigation.

Results: While temperature increased only minimally during cement polymerization, ultrasonic melting and removal of cement with use of constant energy delivery led to markedly elevated temperatures in the humeral cortex, the triceps muscle, and the radial nerve. These temperatures were above the known thresholds for thermal injury and necrosis. Subsequently, strategies designed to allow for safe ultrasonic cement removal from the humerus were applied, including intermittent delivery of energy and the use of cold irrigation between probe passes. These strategies resulted in markedly lower maximum temperatures in all tissues tested.

Conclusions: Temperatures in the humerus, triceps, and, most importantly, the radial nerve can reach potentially dangerous levels when ultrasound technology is used to remove cement from the humerus. We suggest intermittent cold irrigation of the humeral canal, no tourniquet use, education of surgeons with regard to proper techniques designed to limit heat generation, and consideration of exposure and protection of the radial nerve when ultrasound devices are used.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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