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Effect of total shoulder replacements on airport security screening in the post-9/11 era Joshua S. Dines, MD, a Hussein Elkousy, MD, b T. Bradley Edwards, MD, b Gary M. Gartsman, MD, b and David M. Dines, MD, a New York, NY, and Houston, TX There are few reports in the literature on the effect of orthopaedic implants on airport security devices and none on shoulder arthroplasty implants after Septem- ber 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 subse- quently subjected to more intensive screening. We as- sess 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 re- sponded to a questionnaire regarding their travel ex- periences 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 seg- ments 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 interna- tionally, there was a high correlation of activation (R 0.54). Twenty-six patients had multiple joint im- plants (mean, 2.8). Multiple joint implants caused in- creased alarm activation (P .001). All patients re- ported that their travel was delayed during the instances of security activation. There was no statisti- cally 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 indi- cating 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 shoul- der 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 re- placement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment. Doctors often warn their pa- tients 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 spo- radic. This study raises the importance of notifying pa- tients 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. (J Shoulder Elbow Surg 2007;16:434-437.) S ince September 11, 2001, airport security screen- ing 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 screen- ing. These patients may be subjected to extreme time delays, as well as the potential for body searches. In addition, the activation of screening devices by pa- tients with implants puts added stress on the security staff. Security guards must determine the cause of the alarm and the need for more extensive searches. There are few reports in the literature on the effect of orthopaedic implants on airport security devices and none on shoulder arthroplasty implants after 9/11. 1-4 Ideally, doctors should be able to inform their patients of the likelihood of a search and what measures can be taken to expedite the process. In this study, we assess the effects of shoulder joint implants From a Kerlan-Jobe Orthopaedic Clinic, New York, and b Fondren Orthopedic Group, Houston. Reprint requests: Joshua S. Dines, MD, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021(E-mail: [email protected]). Copyright © 2007 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2007/$32.00 doi:10.1016/j.jse.2006.10.016 434

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

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ffect of total shoulder replacements on airport securitycreening in the post-9/11 era

oshua S. Dines, MD,a Hussein Elkousy, MD,b T. Bradley Edwards, MD,b Gary M. Gartsman, MD,b

nd David M. Dines, MD,a New York, NY, and Houston, TX

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here are few reports in the literature on the effect ofrthopaedic implants on airport security devices andone on shoulder arthroplasty implants after Septem-er 11, 2001. Since 9/11, airport security screeningevices have become more sensitive in response to the

ncreasing threat of terrorism. Often, patients with jointmplants activate the metal detectors and are subse-uently subjected to more intensive screening. We as-ess the effects of shoulder joint implants on differentirport security devices and what effect the results hadn passenger travel. In this study, 154 patients whoad previously undergone shoulder replacement re-ponded to a questionnaire regarding their travel ex-eriences after 9/11. Of these, 85 had flown during

he time period studied (47 men and 38 women;ean age, 67.8 years); 79 had traveled domestically

mean, 7 flights), and 22 had taken internationalights (mean, 6.1 flights). The questionnaire addressedach patient’s height/weight, the number of flight seg-ents flown (domestic and international), the numberf times that a patient activated the doorway alarm/and alarm, and the effect of a card stating that theatient had joint replacement (when applicable). Onverage, patients with shoulder replacement travelingomestically activated the security gate 52% of the

ime. The average for international travel was 42%. Ofhe patients who flew both domestically and interna-ionally, there was a high correlation of activationR � 0.54). Twenty-six patients had multiple joint im-lants (mean, 2.8). Multiple joint implants caused in-reased alarm activation (P � .001). All patients re-orted that their travel was delayed during the

nstances of security activation. There was no statisti-ally significant effect of body mass index, height,

rom aKerlan-Jobe Orthopaedic Clinic, New York, and bFondrenOrthopedic Group, Houston.

eprint requests: Joshua S. Dines, MD, Department of OrthopaedicSurgery, Hospital for Special Surgery, 535 E 70th St, New York,NY 10021(E-mail: [email protected]).opyright © 2007 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

058-2746/2007/$32.00

soi:10.1016/j.jse.2006.10.016

34

eight, age, or sex on security device activation. Ofhe patients, 71% were told by their doctor that thehoulder replacement may activate security devices.f these, 46 were given a card by their doctor indi-

ating the presence of a total joint implant. In only0% of the security encounters of these patients did

he card expedite the screening process. This is theargest study on the effects of joint implants, and shoul-er implants in particular, on airport security devicesnd the only one that has analyzed the data of post-/11 travel. Patients traveling after total shoulder re-lacement are often delayed and subjected to moreigorous screening when traveling, especially in theost-9/11 environment. Doctors often warn their pa-

ients of potential problems and may try to avert thisy giving them cards documenting the presence of a

oint implant. The acceptance of these cards is spo-adic. This study raises the importance of notifying pa-ients of potential security delays, especially those withultiple joint implants, as they may directly affect

ravel plans. In addition, these patients may benefitrom the establishment of an international joint registry.J Shoulder Elbow Surg 2007;16:434-437.)

ince September 11, 2001, airport security screen-ng devices have become more sensitive in responseo the increasing threat of terrorism. Often, patientsith joint implants activate the metal detectors andre subsequently subjected to more intensive screen-

ng. These patients may be subjected to extreme timeelays, as well as the potential for body searches. Inddition, the activation of screening devices by pa-

ients with implants puts added stress on the securitytaff. Security guards must determine the cause of thelarm and the need for more extensive searches.

There are few reports in the literature on the effectf orthopaedic implants on airport security devicesnd none on shoulder arthroplasty implants after/11.1-4 Ideally, doctors should be able to inform

heir patients of the likelihood of a search and whateasures can be taken to expedite the process. In this

tudy, we assess the effects of shoulder joint implants

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J Shoulder Elbow Surg Dines et al 435Volume 16, Number 4

n different airport security devices and what effecthe results had on passenger travel.

ATERIALS AND METHODS

This was a retrospective review of 209 patients who hadreviously undergone shoulder replacement surgery. A ques-

ionnaire regarding their travel experiences after 9/11 wasailed to each. Eighty-five patients had flown during the

ime period studied and responded to the questionnaire.he questionnaire addressed each patient’s height andeight, the number of flight segments flown (domesticnd international), the number of times that a patientctivated the doorway alarm/wand alarm, and the effectf a card stating that a patient had joint replacementwhen applicable).

ESULTS

Of the 209 patients contacted, 154 responded74%). Of these, 85 had traveled since 9/11. Thereere 47 male respondents and 38 female respon-ents. The mean age was 67.8 years. The meaneight of the patients was 67.9 in, and the meaneight was 186.7 lb. The body mass index (BMI) of

he patients responding averaged 27.3. Of the pa-ients, 49 had a right-sided shoulder replacement, 24ad a left shoulder arthroplasty, and 12 had bilateralhoulder replacements.

Of the 85 patients, 82 had traveled domestically,ith a mean of 7.0 � 11.3 flights (range, 2-100). Of

hese, 19 also traveled internationally, and 3 patientsad only traveled internationally. The mean numberf international flights for these patients was 6.1 �0.3 (range, 2-50).Regarding activation of the gate alarm, 82 pa-

ients flew a total of 574 domestic flight segments.ate activation occurred in 52% of the flights. Fur-

hermore, 22 patients flew a total of 134 internationalight segments, and they activated the gate 42% ofhe time. Of these 22 patients, 19 activated the gaten 43% � 41% of the domestic flights and 48% �8% of the international flights (these are the patientsho flew both domestically and internationally). Theorrelation is 0.54, meaning that a patient who acti-ated the gate on domestic flights tended to activate itn international flights as well. The difference in per-ent activation between domestic and internationalas not statistically significant (P � .9).When we assessed the 59 patients who had only

ne joint replacement (total shoulder implant), theesults were very similar. The mean patient age was7 years, and the mean BMI was 27.6. Of theatients, 56 flew domestically, with a mean of 8.03ight segments, and 22 flew internationally (mean,.14). Regarding domestic travel in this group, 33 of6 (58.9%) activated the gate alarm at least once.

here were 442 domestic flight segments flown by d

his group. On 245 occasions, they activated the gatelarm (55.4%). All patients who activated the gatelarm were subsequently examined with a wand.and activation occurred 97.9% of the time (240/

45). As all of the patients who flew internationallyad only one total joint replacement (total shouldermplant), the results are the same as mentioned pre-iously for the entire cohort. Again, the differenceetween domestic and international gate activationas not significant. However, there was a strongorrelation between gate activation on domestic andnternational flights (R � 0.54).

Twenty-six patients had multiple prosthetic jointmplants, including total knee, total hip, and totalhoulder replacements. They had a mean of 2.8 jointeplacements (range, 2-5). These patients activatedhe gate alarm 89% of the time, and at all times, theyctivated the wand alarm as well. The correlationetween the number of artificial joints and the chance

hat the gate alarm was triggered equaled 0.5, mean-ng that multiple joint replacements caused increasedlarm activation (P � .001). None of the patients withultiple prostheses traveled internationally.BMI was defined as follows, in accordance with

he Centers for Disease Control and Prevention: lesshan 18.5, underweight; 18.5 to 24.9, normal; 25.0o 29.9, overweight; and greater than 30.0, obese.

n the basis of these criteria, one patient in this studyas underweight. He activated both the gate andand alarms on all 8 flight segments flown. Thereere 27 patients in the normal BMI range, 31 pa-

ients were overweight, and 26 patients were obese.nalysis of both the domestic and international data

evealed no statistically significant effects of BMI onctivation of the gate security system (domestic P �5, international P � .7). No other demographicariables, including age, height, weight, and sex,ad a statistically significant association with percent-ge frequency of gate activation (Table I).

Ninety-six percent of the patients who activated therch detector during domestic travel and eighty-fiveercent of the patients who set off the gate alarm

able I Association of demographic variables with percentagerequency of gate activation

VariableDomesticP value

InternationalP value

ge .5 .4eight .2 .7eight .2 .8

MI .5 .7ex .1 .8ultiple joint replacements �.001 Not applicable

uring international travel felt that their time at airport

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436 Dines et al J Shoulder Elbow SurgJuly/August 2007

ecurity was significantly increased. Despite this, only0 of 85 travelers (71%) were told by their doctor

hat, after surgery, the implant may activate securitylarms at the airport. Forty-six patients were given aard by their physician indicating that they had arosthetic shoulder joint. Of these 46, 14 (30%)ound the card to be helpful at airport security inecreasing potential delays.

ISCUSSION

Typically, there are two types of screening devicessed at airport security gates: arch detectors, throughhich all travelers pass, and handheld detectors,hich are used if the arch detector is activated. Theederal Aviation Administration establishes minimumensitivity levels for both devices, and these levelsave been increased since 9/11. Potential activationf these devices, subsequent searches, and time de-

ays are sources of significant anxiety for many pa-ients with joint replacements. Past reports have citedany factors that influence detection rates, including

mplant mass, speed of passage through the gate,etector model and sensitivity settings, body habitus,nd implant combinations.1–6 Ours is the first study tossess the effects of shoulder arthroplasty on airportecurity devices.

Since 1970, there have only been 9 studies inves-igating the effects of orthopaedic implants on airportecurity devices, and none of these was written after/11.4 (It should be noted that although the study ofamineni et al3 was published in 2002, the work wasubmitted in September 2000). Basu et al1 attempted toetermine which implants used in fracture fixation and

oint replacement activated airport metal detectors. Archetectors at 2 different settings were used on 2 groups ofatients. The first group consisted of healthy patientsith implants strapped to their body. Group 2 com-rised patients with implants in situ. The authors found

hat implants used for fracture treatment usually did notctivate the detector. The Richards cannulated screwRichards, Smith and Nephew, Cambridge, UK) was thexception, as it activated the sensor at higher sensitivityettings. Patients with 1 or 2 joint replacements werenlikely to activate the alarm, but those with 3 or 4 jointmplants activated it at both the low and high settings.he authors concluded that patients with multiple jointmplants should be warned about potential security ac-ivation and given a certificate to present in these in-tances. In our study, there was a statistically significantorrelation between the number of artificial joints andhe chance that the gate alarm was activated. Patientsith 2 or more joint replacements activated the archetector 89% of the time. In addition, we found a muchigher rate of arch activation in those patients with onlyjoint replacement. This may be due in part to the

ore sensitive detection settings used since 9/11. T

Grohs and Gottsauner-Wolf2 studied the detectionf joint replacements based on implant weight. Simi-

ar to the previously mentioned study, 2 groups ofatients were assessed: healthy volunteers with im-lants strapped to their body and those with in situ

oint replacements. The latter group consisted of 15atients (8 unilateral total hip replacements, 4 bilat-ral hip replacements, 2 total knee replacements, andproximal femoral implant). The authors found that

ll implants weighing more than 145 g were detectedy the single-source detector. The degree of detectionas directly related to the logarithm of the weight of

he prosthesis in patients (correlation, 0.61). Theylso found that detection was influenced by transitpeed. Finally, in their study, volunteers with prosthe-es fixed to them were more easily detected thanhose with implanted prostheses, “possibly due to theasking effect of tissue coverage.” In our study, weid not find a statistically significant difference in gatectivation based on BMI. One possible explanation is

he small number of patients who had BMI valuesn the underweight range (n � 1). That being said,heoretically, the process should not be affected byody tissue coverage. When a magnetically activeetal object (ie, humeral prosthesis) moves across thelectromagnetic field generated by the arch detector,n induction current is generated, activating thelarm; soft-tissue coverage should not influence theeneration of current.1

Kamineni et al3 assessed the effects of soft-tissuehield and fast transit through the security arch onmplant detectability. The study group consisted of 12atients with implants in vivo (1 total shoulder re-lacement) and 60 implants in vitro. They found thatandheld (wand) detectors detected all implants, ex-ept 1 ankle arthroplasty. Arch detectors were lessensitive. BMI was correlated to implant detectability,nd no significant effect was found. An exceptionallyast or slow pace through the arch reduced the de-ectability of some implants; however, this finding wasot observed when the speed of transit was within theormal walking paces. In contrast to the work ofrohs and Gottsauner-Wolf,2 stainless steel implantseighing more than 100 g were reliably detected in

he study of Kamineni et al. Similar to our study, BMIad no effect on detection. We also found the wando be more sensitive than the arch detector, althoughhe differences were not statistically significant.

Ours is the largest study on the effects of jointeplacements on airline security and the only oneealing specifically with shoulder replacements. Fur-

hermore, it is the only one based on post-9/11 data.t is readily admitted by the airline industry that secu-ity standards have increased since that date, and thisight explain the higher rate of implant detection inur study compared with those previously published.

he large number of patients in this study allowed us

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J Shoulder Elbow Surg Dines et al 437Volume 16, Number 4

o comment on the statistical significance of previouslyublished observations. Our results corroborate pre-ious reports that BMI does not affect implant detec-ion. We also found that detection directly correlatesith the number of implants that a patient has. In our

tudy, there was a high correlation between domesticnd international security activation, meaning thatatients who activated detectors domestically did so

nternationally as well. This also makes sense in lightf the new security standards that have made domes-

ic travel as safe as international travel.Because a large portion of the patients in this study

ad only total shoulder implants, we were able tonalyze them as a separate group. Their results wereery similar to those of the cohort as a whole. Patientsith total shoulder replacement activated the gatelarm more than 50% of the time, which frequently

ed to significant time delays. This was the case bothomestically and internationally.

Time delays at airport security are an importantactor for persons who are traveling. In this study,ore than 85% of the patients felt that they wereelayed a significant amount of time because of their

mplant. Furthermore, only about 70% of the patientsn the study were told that the implant may activateecurity detectors. As delays at airport security candversely affect travel, physicians performing shoul-er arthroplasty should make their patients aware ofotential delays. Many of the past studies mentioned

he use of cards or identification passes noting the

ocation of the implant to expedite the security clear-

nce process. Because a uniform system does notxist, the cards were rarely helpful in this series ofatients.

Patients traveling after total shoulder arthroplastyre often delayed and subjected to more rigorouscreening when traveling, especially in the post-9/11 en-ironment. Doctors sometimes warn their patients ofotential problems and, often, try to avert this byroviding letters or cards documenting the presencef a joint implant. The acceptance of these cards isporadic. This study raises the importance of notifyingatients of potential security delays, as these mayirectly affect travel plans. Patients with more thanjoint replacement are at an extremely high risk of

eing stopped. They may benefit from the establish-ent of an international joint registry with universally

ecognized cards.

EFERENCES

. Basu P, Packer GJ, Himstedt J. Detection of orthopaedic implants byairport metal detectors. J Bone Joint Surg Br 1997;79:388-9.

. Grohs JG, Gottsauner-Wolf F. Detection of orthopaedic prosthesesat airport security checks. J Bone Joint Surg Br 1997;79:385-7.

. Kamineni S, Legge S, Ware H. Metallic orthopaedic implants andairport metal detectors. J Arthroplasty 2002;17:62-5.

. Pearson WG. Matthews LS. Airport detection of modern orthopae-dic implant metals. Clin Orthop Relat Res 1992:261-2.

. Sperling KP, Gebuhr PH. Metal detectors at airports can beactivated by orthopedic metal implants [in Danish]. Ugeskr Laeger1995;157:2153-4.

. van der Wal BCH, Grimm B, Heyligers IC. Airport detectors and

orthopaedic implants. Acta Orthop Belg 2005;71:379-84.