Metallic orthopaedic implants and airport metal detectors

The Metal in My Body: Patients' Perception and Attitude Toward Orthopedic Implants

INTRODUCTION

Metal implants are broadly used in orthopedics and traumatology to stabilize bone fragments. This study aimed to explore patients' awareness, body image, and overall experience of living with a metal implant after a fracture.

METHODS

A mixed methods convergent design (QUAN+QUAL) was adopted. A self-reported 30-item questionnaire was used to investigate patients' perception and apprehension of the implantation of orthopedic materials. To enlighten the quantitative findings, semi-structured interviews followed till data saturation. Quantitative and qualitative data were compared during the analysis phase.

RESULTS

Results showed that women's and elders' acceptance of the implants was greater than that of men and younger patients even in acute cases. The sense of superiority provided by the implant was mainly reported by the elderly (adjusted odds ratio (ORadj) for increasing age: 1.06; 95% CI: 1.02-1.1; p<0.01), and the sense of inferiority was mainly reported by young men (ORadj: 6.19; 95% CI: 2.36-16.22; p<0.01). Similarly, women and elderly mostly tended to answer that the injured limb felt stronger after the implant placement, while young men tended to answer a sense of weakness with the implant (ORadj for increasing age: 1.06; 95% CI: 1.03-1.09; ORadj for male gender: 4.67; 95% CI: 1.87-11.7; p<0.01 for both regressions). Most participants (56.6%) and mainly young participants, regardless of gender, expressed the desire to get the metal implants removed (ORadj for increasing age: 0.91; 95% CI: 0.89-0.95; p<0.01). Misinformation and misconception were also found in a high percentage of the questioned patients (48.1%). Thematic analysis of the interviews revealed that none of the participants directly attributed any change in their life, self, or body image to the implants. An altered body image was not reported. The most reported experience was the restriction of movement due to the accident or the subsequent physical weakness.

CONCLUSION

Despite the acceptance of the implant being great, the level of patient knowledge was fairly low. The present study highlights the importance of providing patients with information throughout their management to avoid misunderstandings. Age and gender did influence patients' perception of the implants. Personalized assessment is further needed to address body image issues after an implant placement procedure.

The impact of modern airport security protocols on patients with total shoulder replacements

BACKGROUND

Advancements in airport screening measures in response to 9/11 have resulted in increased false alarm rates for patients with orthopedic and metal implants. With the implementation of millimeter-wave scanning technology, it is important to assess the changes in airport screening experiences of patients who underwent total shoulder arthroplasty (TSA).

METHODS

Here, 197 patients with prior anatomic and reverse TSA completed between 2013 and 2020 responded to a questionnaire regarding their experiences with airport travel screening after their operation. Of these patients, 86 (44%) stated that they had traveled by plane, while 111 (56%) had not. The questionnaire addressed several measures including the number of domestic and international flights following the operation, number of false alarm screenings by the millimeter-wave scanner, patient body habitus, and presence of additional metal implants.

RESULTS

A total of 53 patients (62%) responded "yes" to false screening alarms due to shoulder arthroplasty. The odds of a false screening alarm for patients with other metal implants was 5.87 times that of a false screening alarm for patients with no other metal implants (P<0.1). Of a reported 662 flights, 303 (45.8%) resulted in false screening alarms. Greater body mass index was not significantly lower in patients who experienced false screening alarms (P=0.30).

CONCLUSIONS

Patients with anatomic and reverse TSA trigger false alarms with millimeter-wave scanners during airport screening at rates consistent with prior reports following 9/11. Patient education on the possibility of false alarms during airport screening is important until improvements in implant identification are made. Level of evidence: IV.

Positive security screening episodes of patients with spinal implants are influenced by detector type and not implant material

BACKGROUND CONTEXT

Previous research on rates of spinal detection showed a low frequency of patients (5%) experienced delays and additional screening going through airport security. With continuous technology advances in screenings and the rise in cobalt chrome implantation, updated data on patient experiences was needed.

PURPOSE

1) Assess the rates of detection and additional screening by traditional metal detectors and full body scanners in patients with metal spinal implants, 2) Compare the rates of detection of various metal types (Titanium and cobalt-chrome, titanium only, and stainless steel) STUDY DESIGN: Retrospective PATIENT SAMPLE: All spine surgical follow-ups over survey period.

OUTCOME MEASURES

Self-reported open questionnaire; frequency of airport screening, patients' feelings and attitudes towards screening.

METHODS

Patients were surveyed in the outpatient setting on exposure to metal detectors (Traditional and full-body scanners) after spinal surgery with metallic implants at a single institution. A total of 182 patients were identified and consented. The medical records were reviewed for details on implant material and location.

RESULTS

Mean age at surgery was 53 years (range=12-88) with a mean 5.9 levels fused (range 2-20). Mean time from surgery to survey was 34 months (range=2-351) and number of airport screenings was 5.8 (range=0-54). The most common implants were titanium/cobalt-chrome (Ti/CoCr) (n=96, 53%) and titanium only (n=72, 40%). Overall, 40% of patients reported a detector alert at an airport requiring processing delay and additional screening: 86% from full body scanners, 54% from traditional metal detectors, and 41% of patients reporting both. Full body scanners were more likely to detect implants compared to traditional metal detectors (OR 5.1, p<.0001). No significant difference in number of screenings between patients who set off detectors and patients who did not (p=.185). Twenty percent of patients reported trouble at non-airport locations with detectors due to their spinal implants, with 70% of these patients reporting additional manual screenings. There was no correlation between levels spanned by the construct and number of times detected by traditional metal detectors or full body scanners, and no significant difference between levels spanned by constructs, or construct locations, in patients who set off detectors and those who did not. There was no significant difference between Ti/CoCr vs. titanium or other constructs in positive screenings. Subanalysis of fusions <5 levels demonstrated Ti/CoCr implants did not have an impact on positive screenings vs. other metal types (OR 0.88, p=.756). Interestingly, there was a significant difference in age and the positive screenings (p=.0025). Patients 60+ years of age had statistically significant greater positive screening than patients 0 to 40 years and 41 to 60 years. This data raises the possibility the presence of total joint arthroplasties (Mean age of patients with arthroplasty 65.5 years, range 50-88) likely play a significant role in the frequency of positive screenings.

CONCLUSIONS

40% of patients had their spinal implants detected at airports and 20% reported detections at other non-airport locations. Full body scanners detect spinal implants more frequently compared to traditional metal detectors (86% vs. 54% of detections, respectively). There was no difference in rate of airport and non-airport detection in patients with cobalt chrome implants compared to other materials. The presence of total joint arthroplasties likely has a significant contribution to the detector alerts.

Detection of total hip arthroplasties at airport security checkpoints - how do updated security measures affect patients?

INTRODUCTION

There have been historical reports on the experiences of patients with total hip arthroplasty (THA) passing through standard metal detectors at airports. The purpose of this study was to analyse those who had recently passed through airport security and the incidence of: (i) triggering of the alarm; (ii) extra security searches; and (iii) perceived inconvenience.

METHODS

A questionnaire was given to 125 patients with a THA during a follow-up appointment. Those who had passed through airport security after January 2014 met inclusion criteria. A survey was administered that addressed the number of encounters with airport security, frequency of metal detector activation, additional screening procedures utilised, whether security officials required prosthesis documentation, and perceived inconvenience.

RESULTS

51 patients met inclusion criteria. 10 patients (20%) reported triggered security scanners. 4 of the 10 patients stated they had surgical hardware elsewhere in the body. 13 of the 51 patients (25%) believed that having their THA increased the inconvenience of traveling. This is different from the historical cohort with standard metal detectors which patients reported a greater incidence of alarm triggering (n = 120 of 143; p = 0.0001) and perceived inconvenience (n = 99 of 143; p = 0.0001).

DISCUSSIONS

The percentage of patients who have THA triggering security alarms has decreased. Furthermore, the number of patients who feel that their prosthesis caused traveling inconvenience has decreased. We feel that this decrease in alarms triggered and improved perceptions about inconvenience are related to the increased usage of new technology.

Detection of In Vivo Foot and Ankle Implants by Walkthrough Metal Detectors

BACKGROUND

Heightened security concerns have made metal detectors a standard security measure in many locations. While prior studies have investigated the detection rates of various hip and knee implants, none have looked specifically at the detection of foot and ankle implants in an in vivo model. Our goals were to identify which commonly used foot and ankle implants would be detected by walkthrough metal detectors both in vivo and ex vivo.

METHODS

Over a 7-month period, 153 weightbearing patients with foot and ankle hardware were recruited to walk through a standard airport metal detector at 3 different program settings (buildings, airports, and airports enhanced) with a base sensitivity of 165 (arbitrary units), as currently used by the Transportation Security Administration. The number of implants, location and type, as well as the presence of concomitant hardware outside of the foot and ankle were recorded. To determine the detection rate of common foot and ankle implants ex vivo, different hardware sets were walked through the detector at all 3 program settings.

RESULTS

Seventeen patients were found to have detectable hardware at the buildings, airports, and airports enhanced settings. An additional 3 patients had hardware only detected at the airports enhanced setting. All 20 of these patients had concomitant metal implants outside of the foot and ankle from other orthopaedic procedures. All patients with foot and ankle implants alone passed through undetected. Seven hardware sets were detected ex vivo at the airports enhanced setting.

CONCLUSION

Our results indicate that patients with foot and ankle implants alone are unlikely to be detected by walkthrough metal detectors at standard airport settings. When additional hardware is present from orthopaedic procedures outside of the foot and ankle, metal detection rates were higher. We believe that these results are important for surgeons in order to educate patients on how they might be affected when walking through a metal detector such as while traveling.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Airport metal detector activation is rare after posterior spinal fusion in children with scoliosis

PURPOSE

Since the September 11, 2001 terrorist attacks on the World Trade Center in New York City, travel security has become an ever-increasing priority in the United States. Frequent parent and patient inquiry and recent literature reports have generated interest in the impact of heightened security measures on patients with orthopaedic implants, and have indicated increasing rates of metal detector triggering. There are no reports to date, however, evaluating children and adolescents who have undergone posterior spinal fusion for scoliosis, so responses to patient and parent inquiries are not data-driven. The purpose of this study is to determine the frequency of airport metal detector triggering by patients who have had posterior-only spinal fusion and to characterise any potential predictors of metal detector activation.

METHODS

A cross-sectional study was performed by interviewing 90 patients who underwent posterior-only spinal fusion for a diagnosis of juvenile or adolescent idiopathic scoliosis and have travelled by air in the past year. Demographic, clinical and surgical instrumentation data were collected and evaluated, along with patients' reports of airport metal detector triggering and subsequent screening procedures.

RESULTS

Five patients with stainless steel instrumentation (5.6 % of the cohort) triggered an airport walkthrough metal detector, and an additional five patients who did not trigger an airport detector triggered a handheld detector at a different venue. All patients who triggered an airport metal detector had stainless steel instrumentation implanted prior to 2008, and no patient with titanium instrumentation triggered any detector in any venue. All trigger events required subsequent screening procedures, even when an implant card was presented.

CONCLUSIONS

In this cohort of children and adolescents with posterior spinal instrumentation, airport walkthrough metal detector triggering was a rare event. Therefore, we advise patients and families with planned posterior scoliosis fusions using titanium instrumentation that airport detection risk is essentially non-existent, and only rare for those with planned stainless steel instrumentation. We no longer issue implant cards postoperatively, as these did not prevent further screening procedures in this cohort.

LEVEL OF EVIDENCE

Prognostic level 2.

STUDY DESIGN

cross-sectional.

Prosthetic metal implants and airport metal detectors

INTRODUCTION

Metal detectors have been present in airports and points of departure for some time. With the introduction of heightened security measures in response to fears of an increased threat of terrorism, they may become more prevalent in other public locations. The aim of this study was to ascertain which prosthetic devices activated metal detector devices used for security purposes.

METHODS

A range of prosthetic devices used commonly in orthopaedic and plastic surgery procedures were passed through an arch metal detector at Birmingham Airport in the UK. Additionally, each item was passed under a wand detector. Items tested included expandable breast prostheses, plates used in wrist and hand surgery, screws, K-wires, Autosuture™ ligation clips and staples.

RESULTS

No prostheses were detected by the arch detector. The expandable implants and wrist plates were the only devices detected by passing the wand directly over them. No device was detected by the wand when it was under cover of the axillary soft tissue. Screws, K-wires, Autosuture™ clips and staples were not detected under any of the study conditions.

CONCLUSIONS

Although unlikely to trigger a detector, it is possible that an expandable breast prosthesis or larger plate may do so. It is therefore best to warn patients of this so they can anticipate detection and further examination.

Detection of total knee prostheses at airport security checkpoints

Airport security screening measures have changed substantially during the past decade, but few reports have examined how this affects patients who have undergone knee arthroplasties. The purpose of this study was to characterize the efficacy of airport metal detection of total knee prostheses, the delays faced, any inconvenience this may have caused, and the role of implant identification cards. Ninety-seven total knee arthroplasty recipients reported passing through an airport metal detector, with 70 triggering the alarm a mean of 3 times (range, 1-36). The presence of a single-knee prosthesis triggered airport security alarms more than 83% of the time and increased patient inconvenience. Patients should be informed about this chance and be prepared to present documentation of their prosthesis.

Detection of total hip prostheses at airport security checkpoints: how has heightened security affected patients?

BACKGROUND

The sensitivity of airport security screening measures has increased substantially during the past decade, but few reports have examined how this affects patients who have undergone hip arthroplasty. The purpose of this study was to determine the experiences of patients who had hip prostheses and who passed through airport security screenings.

METHODS

A consecutive series of 250 patients who presented to the office of a high-volume surgeon were asked whether they had had a hip prosthesis for at least one year and, if so, whether they had flown on a commercial airline within the past year. Patients who responded affirmatively to both questions were asked to complete a written survey that included questions about which joint(s) had been replaced, the number of encounters with airport security, the frequency and location of metal detector activation, any additional screening procedures that were utilized, whether security officials requested documentation regarding the prosthesis, the degree of inconvenience, and other relevant information.

RESULTS

Of the 143 patients with hip replacements who traveled by air, 120 (84%) reported triggering the alarm and required wanding with a handheld detector. Twenty-five of these patients reported subsequently having to undergo further inspection, including additional wanding, being patted down, and in two cases having to undress in a private room to show the incision. Ninety-nine (69%) of the 143 patients reported that the prosthetic joint caused an inconvenience while traveling.

CONCLUSIONS

This study provides interesting and critical information that allows physicians to understand the real-world implications of implanted orthopaedic devices for patients who are traveling where there has been heightened security since September 11, 2001. Patients should be counseled that they should expect delays and be prepared for such inconveniences, but that these are often only momentary. This information could relieve some anxiety and concerns that patients may have prior to traveling.

Effect of total shoulder replacements on airport security screening in the post-9/11 era

There are few reports in the literature on the effect of orthopaedic implants on airport security devices and none on shoulder arthroplasty implants after September 11, 2001. Since 9/11, airport security screening devices have become more sensitive in response to the increasing threat of terrorism. Often, patients with joint implants activate the metal detectors and are subsequently subjected to more intensive screening. We assess the effects of shoulder joint implants on different airport security devices and what effect the results had on passenger travel. In this study, 154 patients who had previously undergone shoulder replacement responded to a questionnaire regarding their travel experiences after 9/11. Of these, 85 had flown during the time period studied (47 men and 38 women; mean age, 67.8 years); 79 had traveled domestically (mean, 7 flights), and 22 had taken international flights (mean, 6.1 flights). The questionnaire addressed each patient's height/weight, the number of flight segments flown (domestic and international), the number of times that a patient activated the doorway alarm/wand alarm, and the effect of a card stating that the patient had joint replacement (when applicable). On average, patients with shoulder replacement traveling domestically activated the security gate 52% of the time. The average for international travel was 42%. Of the patients who flew both domestically and internationally, there was a high correlation of activation (R = 0.54). Twenty-six patients had multiple joint implants (mean, 2.8). Multiple joint implants caused increased alarm activation (P < .001). All patients reported that their travel was delayed during the instances of security activation. There was no statistically significant effect of body mass index, height, weight, age, or sex on security device activation. Of the patients, 71% were told by their doctor that the shoulder replacement may activate security devices. Of these, 46 were given a card by their doctor indicating the presence of a total joint implant. In only 30% of the security encounters of these patients did the card expedite the screening process. This is the largest study on the effects of joint implants, and shoulder implants in particular, on airport security devices and the only one that has analyzed the data of post-9/11 travel. Patients traveling after total shoulder replacement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment. Doctors often warn their patients of potential problems and may try to avert this by giving them cards documenting the presence of a joint implant. The acceptance of these cards is sporadic. This study raises the importance of notifying patients of potential security delays, especially those with multiple joint implants, as they may directly affect travel plans. In addition, these patients may benefit from the establishment of an international joint registry.

Detection of orthopaedic implants by airport metal detectors

INTRODUCTION

We performed a questionnaire study to establish the frequency and consequences of the detection of orthopaedic implants by airport security and to help us advise patients correctly. All published literature on this subject is based on experimental studies and no 'real-life' data are available.

PATIENTS AND METHODS

A total of 200 patients with a variety of implants were identified. All patients were sent a postal questionnaire enquiring about their experience with airport security since their surgery.

RESULTS

Of the cohort, 154 (77%) patients responded. About half of the implants (47%) were detected, but the majority of patients (72%) were not significantly inconvenienced. When detected, only 9% of patients were asked for documentary evidence of their implant. We also found that patients with a total knee replacement (TKR) had a greater chance of detection as compared to those with a total hip replacement (THR; 71% versus 31%; P = 0.03).

CONCLUSIONS

All patients, and in particular those with a TKR, can be re-assured that, although they have a fair chance of detection by airport security, a major disruption to their journey is unlikely. We advise that documentation to prove the presence of an orthopaedic implant should be offered to those who are concerned about the potential for inconvenience, but such documentation is not required routinely.

Detection of orthopaedic implants by airport metal detectors

OBJECTIVES

To report the effect of patient's body mass index (BMI), implant type, size, location, number, and material on detection by certified Transportation Security Administration (TSA) and Federal Aviation Administration (FAA) airport metal detectors set to today's standard sensitivity.

DESIGN

Retrospective clinical study.

SETTING

Level 1 university trauma center.

PATIENTS

Ninety-six regularly scheduled trauma clinic patients with a wide variety of orthopaedic implants were enrolled in the study from August 2004 through December 2004.

INTERVENTION

Patients walked through an airport arch metal detector and were also wanded with a handheld metal detector.

MAIN OUTCOME MEASUREMENTS

Detection of implants by arch detector or wand was recorded. We also gathered information regarding BMI, location of implants, type, metal composition, and size.

RESULTS

All unilateral prostheses (8/8) and bilateral prostheses (1/1) were detected. Subjects with 4 or fewer screws and no other implants were never detected by the arch metal detector (0/7). For the remaining 78 subjects, the 2 best predictors of detection by the arch were having plates of length >10 holes and having titanium nails (P < 0.001 for each predictor, Wald's test for effects in a logistic model).

CONCLUSIONS

Prostheses, plates of length >10 holes, and titanium nails were the best predictors of detection by the arch. These 3 factors accounted for 42 of the 43 detections by the arch. Body mass index was not shown to affect detectability of orthopaedic implants.

Detection of orthopaedic foot and ankle implants by security screening devices

BACKGROUND

A common question asked by patients contemplating foot and ankle surgery is whether the implants used will set off security screening devices in airports and elsewhere. Detectability of specific implants may require the orthopaedic surgeon to provide attestation regarding their presence in patients undergoing implantation of these devices. Only two studies have been published since security measures became more stringent in the post-9/11 era. None of these studies specifically focused on the large numbers of orthopaedic foot and ankle implants in use today. This study establishes empiric data on the detectability by security screening devices of some currently used foot and ankle implants.

METHODS

A list of foot and ankle procedures was compiled, including procedures frequently used by general orthopaedists as well as those usually performed only by foot and ankle specialists. Implants tested included those used for open reduction and internal fixation, joint fusion, joint arthroplasty, osteotomies, arthroreisis, and internal bone stimulation. A test subject walked through a gate-type security device and was subsequently screened using a wand-type detection device while wearing each construct grouping. The screening was repeated with the implants placed within uncooked steak to simulate subcutaneous and submuscular implantation.

RESULTS

None of the implants were detected by the gate-type security device. Specific implants that triggered the wand-type detection device regardless of coverage with the meat were total ankle prostheses, implantable bone stimulators, large metatarsophalangeal hemiarthroplasty, large arthroreisis plugs, medial distal tibial locking construct, supramalleolar osteotomy fixation, stainless steel bimalleolar ankle fracture fixation, calcaneal fracture plate and screw constructs, large fragment blade plate constructs, intramedullary tibiotalocalcaneal fusion constructs, and screw fixation for calcaneal osteotomies, ankle arthrodeses, triple arthrodeses, and stainless steel first metatarsophalangeal joint arthrodeses. The placement of implants in meat prevented the detectability of only the stainless steel Jones fracture implant (stainless steel 6.5-mm cannulated screw) and the stainless steel midfoot fusion construct (four stainless steel 4.0-mm cannulated screws).

CONCLUSIONS

These data may help the orthopaedic surgeon in counseling patients as to the detectability of some orthopaedic foot and ankle implants in use today. Specific constructs for which documentation may need to be provided to the patient are identified. As security standards evolve and the environments in which they are practiced change, empiric testing of many of these devices may need to be repeated.